Video-assisted thoracoscopic surgery resection and reconstruction of thoracic trachea in the management of a tracheal neoplasm

Intratracheal tumor is a rare tumor, accounting for only 2% of upper respiratory tract neoplasms. Its symptoms are similar to those of head and neck cancers, including coughing up blood, sore throat, and airway obstruction. The diagnosis of this disease is often based on the findings of fibrobronchoscopy or computed tomography (CT). Surgery remains the treatment of choice for tracheal tumor. In patients with benign neoplasms or if the tumors have limited involvement, fibrobronchoscopic resection of the tumor can be performed. For malignant tumors, however, radical resection is required. In the past, open incision is used during the surgery for tumors located in thoracic trachea. Along with advances in video-assisted thoracoscopic surgery (VATS) minimally invasive techniques and devices, VATS resection and reconstruction of the trachea can achieve the radical resection of the tumor and meanwhile dramatically reduce the injury to the patients. In this article we describe the application of VATS resection and reconstruction of trachea in the management of a tracheal neoplasm.     

Flexible bronchoscopic excision of a tracheal mass under extracorporeal membrane oxygenation

Tracheal tumor is a rare but life-threatening condition that can cause obstruction of the airway. Management of tracheal tumors is very challenging and includes surgical resection, radiotherapy, and therapeutic bronchoscopy. Herein, we present a very rare case of an 88-year-old female patient with a tracheal mass due to direct invasion of a mediastinal teratoma. We devised a new method for resection of the tracheal mass because management of her airway and the tracheal mass by conventional methods was impossible. We successfully resected the tracheal mass with flexible bronchoscopic electrocautery under extracorporeal membrane oxygenation (ECMO) without any complications. When management of a patient’s airway and tracheal mass are impossible by conventional methods, this technique may be very useful.     

Surgical treatment of long-segment tracheal anomalies in infants and children

BACKGROUND: Tracheal stenosis in combination with vascular and/or cardiac anomalies is a life-threatening condition in infants and children presenting with severe symptoms of airway obstruction. The optimal surgical treatment of these cases remains controversial. OBJECTIVES: We present here a group of infants and children with combined tracheal malformations and vascular and/or cardiac anomalies. More than 30 % of the stenotic trachea was resected in a subgroup of the patients. A reconstruction with end-to-end anastomosis was achieved on the basis of extensive mobilization of the whole tracheobronchial tree and use of CPB. METHODS: The clinical outcome in 37 children with a median age of 8 (1 - 72) months was analyzed retrospectively. The patients presented with severe airway obstruction in combination with congenital heart defects and/or vascular anomalies. Cardiac catheterization, bronchoscopy and thoracic computer tomography were performed prior to operation. The operations were performed under CPB and consisted of tracheal resection with end-to-end anastomosis or external stabilization. Associated intracardiac and vascular anomalies were repaired simultaneously. RESULTS: All but 1 patient survived and had a straightforward recovery. The patients were extubated under bronchoscopic control with a median intubation time after airway repair of 12.2 days. The average follow-up was 8.4 years (1 - 14 years) and the surviving patients did not show signs of restenosis clinically. A segment longer than 30 % of the tracheal length was resected and reconstructed with end-to-end anastomosis in 57 % of the patients (12 of 21 patients). CONCLUSIONS: Our experience demonstrates that resection of tracheal stenosis and end-to-end anastomosis can be achieved successfully even in cases with stenosis of more than 30 % of the total tracheal length. The use of CBP allowed extensive mobilization of the tracheobronchial tree and resection with end-to-end tension-free anastomotic reconstruction.     

气道神经鞘瘤1例

目的 提高对气道神经鞘瘤的认识,减少对该病的误诊和漏诊.方法 回顾我院收治的1例气道神经鞘瘤患者的病历资料,探讨对该病的诊断及病变特点.结果 患者反复活动后气促1年,肺功能正常,胸部CT提示气道肿物.气管镜活检病理示气道慢性炎症.气管切开行肿物消融术,病理诊断为神经鞘瘤.结论 气道神经鞘瘤临床表现不特异,不易早期诊断,临床易漏诊延误诊断,手术切除仍是治疗气道神经鞘瘤最有效的方法.     

Tracheal rupture after endotracheal intubation: experience with management in 13 cases

BACKGROUND: Tracheal rupture is a rare complication of endotracheal intubation. Potential causes, diagnosis, management, and outcome of cases treated at an university hospital are analysed. PATIENTS AND METHODS: This is a retrospective report on thirteen cases of tracheal rupture related to tracheal intubation, treated at our institution from February 1989 to May 2002. In all patients, the tracheal rupture was confirmed by fiberoptic bronchoscopy. RESULTS: Eleven patients underwent primary repair through a right thoracotomy. Three postoperative deaths unrelated to the tracheal lesion occurred. All remaining cases showed an uneventful recovery after surgical therapy. Two lacerations of the cervical part of the trachea were treated nonsurgically with a satisfactory outcome. CONCLUSIONS: Prognosis of tracheal ruptures depends both on the underlying disease and general condition of the patient and on the rapidity of diagnosis and treatment. Surgical therapy is preferred as it allows reconstruction of the trachea and drainage of the mediastinum. Conservative management appears to be justified for small ruptures in the upper third of the trachea without mediastinitis.     

Functional diagnosis in surgery of the large airways

The main indications for surgery of the airways are (1) non-tumorous airway stenosis and (2) tumors of the large airways with and without relevant stenoses. The aim of the following study was to find out which degree of stenosis is an absolute indication for resection and to what extent the functional disturbances are reversible following surgery. We investigated various groups of patients (stenosis of the trachea, lobectomy with sleeve resection, extended pneumectomy with resection of the distal trachea, pneumectomy with resection of the bifurcation, resection of the main bronchus and lobectomy, rupture of the main bronchus) from 1978 to 1982, before and up to 3 years after surgery. Body-plethysmography (one second forced expiratory volume = FEV1; one second forced inspiratory volume = FIV1; Residual volume = RV; total lung capacity = TLC; airway resistance = Raw; specific airway conductance = sGaw), flow volume relation measurements (maximal inspiratory flow = Vmax insp; maximal expiratory flow = Vmax exp; and flow at various lung volumes), blood gas analysis and an endoscopic estimation of the tracheal diameter were performed. Tracheal resection with end-to-end anastomosis in patients with non-tumerous tracheal stenosis improved the tracheal diameter from 6.0 to 11.7 mm, the sGaw from 0.04 to 0.08 (cmH2O s)-1 and the severity of dyspnea significantly. There was no measurable change in airway caliber following administration of beta 2-adrenergics. The most sensitive parameters for describing the tracheal stenosis are the resistance and flow volume values. A tracheal diameter smaller than 6.5 mm corresponding to a sGaw smaller than 0.03 (cmH2O s)-1 procedured severe dyspnea, which is incompatibly with normal life.(ABSTRACT TRUNCATED AT 250 WORDS)     

Use of cardiopulmonary bypass for tracheal resection: a case report

Although ventilatory support can be life-saving, it also has adverse effects, including postintubation tracheal stenosis caused by damage to the larynx and trachea. Cardiopulmonary bypass is generally not used for the surgical management of tracheal stenosis; however, we have found that the use of cardiopulmonary bypass can be advantageous during tracheal resection and reconstruction.     

Tracheal restenosis after removal of long-term placed Ultraflex expandable metallic stents

Restenosis of trachea after stent placement and removal in patients with malignant airway obstruction has rarely been reported. Here, we reported a 47-year-old woman with large B cell lymphoma at the mediastinum. It was obstructing the trachea and left main bronchus. Two Ultraflex expandable metallic stents were placed immediately due to acute respiratory distress. She underwent concurrent chemoradiotherapy for the lymphoma with good response. Because granulation tissue overgrew the upper margin of the trachea stent and caused frequent sputum impaction, stents were removed after 21 months. Dyspnea developed 8 months later. Bronchoscopy revealed restenosis from granulation tissue and fibrosis at the previous upper margin of the trachea stent. Segmental resection of trachea with primary anastomosis was performed and the patient recovered. Thus, tracheal restenosis may still occur in malignant obstruction patient undergoing Ultraflex stents insertion. Surgery remains a feasible treatment if underlying malignancy is in remission.     

Late complications of tracheotomy

Complications of tracheotomy are largely preventable. Although some authors cite these complications as indications for prolonged endotracheal intubation to avoid tracheotomy, others believe that the laryngotracheal complications of prolonged endotracheal intubation warrant early tracheotomy. Obviously, unnecessary tracheotomies should not be performed, and the controversy regarding the timing of conversion of endotracheal intubation to tracheotomy is handled in an earlier article in this issue. We feel, however, that a properly performed tracheotomy has a low incidence of complications that are more easily managed than are the complex laryngotracheal complications of prolonged endotracheal intubation. Significant post-tracheotomy tracheal stenosis occurs in 8% of patients and is secondary to an overly large tracheotomy stoma or damage at the tracheostomy tube cuff site. Stoma stenosis can be minimized by not making an overly large tracheal stoma and by prevention of undue leverage on the tracheostomy tube. Cuff stenosis can be minimized by the use of the high-volume low-pressure cuffs with careful prevention of overdistention of the cuff. Bronchoscopic dilatation, laser resection, and Silastic T-tube placement provide control of the airway until definitive surgical resection and reconstruction can be performed safely. Tracheoesophageal fistula is an uncommon but life-threatening complication that can be prevented by avoiding overdistention of the tracheostomy tube cuff and by avoiding the concomitant use of a stiff nasogastric tube. These patients are best managed conservatively until they are able to be weaned from a ventilator. A single-stage repair of both the esophagus and the trachea should then be done. Tracheoinnominate artery fistula can be avoided by correct placement of the tracheostomy stoma through the second and third tracheal rings rather than lower in the trachea and by avoidance of overinflation of tracheostomy tube cuffs.     

Non-intubated resection and reconstruction of trachea for the treatment of a mass in the upper trachea

Tumors of the upper trachea are typically treated by tracheal resection and reconstruction via neck incision under general anesthesia. In recent years, non-intubated thoracic surgery has been widely applied for the treatment of lung diseases due to its advantages including quick postoperative recovery. In this article, we describe the application of non-intubated tracheal resection and reconstruction in one patient for the treatment of a mass in upper trachea.     

Benign tracheoesophageal fistula: results of surgical therapy

Acquired fistulas between the trachea and the esophagus (TEFs) are unusual, serious and still challenging clinical entities. Between 1980 and 1997, 31 patients with acquired benign TEF were evaluated and treated in our department. The definitive treatment was undertaken when patients were weaned from the ventilator. Dissection of the fistula and closure of the tracheal and esophageal defect was performed in 26 patients. Esophagogastroplasty plus closure of the tracheal defect and omental interposition was performed in two patients. Tracheal resection and reconstruction plus of the sternocleidomastoid muscle interposition was carried out in one patient with circumferential tracheal damage. In two patients, no surgical treatment was carried out. One patient died after surgical treatment. In 23 patients, long-term follow-up was excellent, with normal post-operative function of both the esophagus and the airway. Two failures of treatment occurred which required definitive tracheostomy plus T-tube. Management of TEFs can be safely carried out after weaning patients from the ventilator.     

Anaesthetic management of acquired non malignant tracheo-oesophageal fistula

Acquired non malignant tracheo-oesophageal fistula is an uncommon complication of endotracheal intubation and tracheostomy. Patients are usually diagnosed while on mechanical ventilation. The rationale of management is to prevent pulmonary contamination, maintain nutrition and achieve spontaneous ventilation prior to surgical repair. Cautious management of the airway is required during tracheal reconstruction. We present a case of non malignant tracheo-oesophageal fistula in which repair was achieved by primary closure of the tracheal and oesophageal defects.     

A rare tracheal malignant tumor: mucoepidermoid carcinoma (a case report)

An 18-year-old male preferred to our clinic with hemoptysis, cough, dyspnea and stridor. A wide-based polypoid tumor that was localized at the right wall of the distal trachea was observed over 3 cm from the carina by flexible bronchoscope. Computerized tomography showed an intraluminal soft tissue density mass in the trachea. Though right thoracotomy, a tracheal resection that contains three rings of the trachea with malignant lesion was performed. Pathologic examination reported a tracheal mucoepidermoid carcinoma. The patient is alive without recurrence three years after surgery.     

原发性气管、隆突肿瘤外科治疗48例临床分析

目的总结原发性气管、隆突肿瘤外科治疗经验。方法回顾分析我科2001-2010年手术治疗48例气管、隆突肿瘤的临床资料,气管环形切除＋对端吻合35例,气管＋隆突切除重建12例,气管楔形切除1例;5例术中辅助体外循环。结果无围手术期死亡,临床治愈41例（85.4%）;术后随访7个月-7年,死亡5例（10.4%）,生存至今43例（89.6%）,其中生存5年及以上者9例（18.8%）;5例术中辅助体外循环28~46 min,平均36 min,麻醉满意。结论气管、隆突肿瘤外科手术疗效确切,合理选择手术方式,适当应用体外循环技术可提高手术安全性。     

Video-assisted thoracoscopic surgery tracheal resection and carinal reconstruction for tracheal adenoid cystic carcinoma

We report a case of video-assisted thoracoscopic surgery (VATS) tracheal resection and carinal reconstruction in a patient with tracheal tumor. The patient presented with adenoid cystic carcinoma (ACC) of the distal trachea, extending along the right main bronchus with carinal invasion. The reconstruction procedure was assisted with cross-field ventilation. Postoperative clinical course of this case was good. The forced expiratory volume in the first second (FEV₁) improved from 0.461 L (17% pred.) to 2.31 L (87% pred.) 1 month after the operation. VATS tracheal resection and carinal reconstruction is a feasible option for patients with tracheal tumor with carina involvement.     

Granular cell myoblastoma: rare localization in the trachea. Report of a case and review of the literature

Granular cell myoblastoma is an uncommon tumor in the respiratory tract. It usually occurs in the tongue, skin, breast, or subcutaneous tissue. When it occurs in the respiratory tract, it is usually located in the bronchus or larynx. Primary tracheal location is rare with only nine such cases reported in the literature. This report describes a 26-year-old woman with granular cell myoblastoma of the trachea. She presented with a four-year history of bronchial asthma. The tumor was surgically excised by tracheal resection and reconstruction. The patient has remained well and free of obstructive airway symptoms, without recurrence of the tumor for more than one year.     

Huge intrathyroidal hematoma causing airway obstruction: a multidisciplinary challenge.

Thyroid hemorrhage is a relatively frequent event that in most cases causes pain and discomfort only, while rarely can cause significant neck swelling. Even more rarely, however, extensive thyroid hemorrhage can result in a rapidly expanding hematoma with airway compromise. We report a case of a rapidly expanding thyroid hemorrhage that occurred secondary to oral anticoagulation therapy in an 80-year-old patient with a previously existing goiter. The patient presented with acute onset of neck pain, dysphagia, and respiratory distress caused by tracheal compression from the thyroid mass. Computed tomography demonstrated a 6 x 9 x 10 cm mass consistent with an intrathyroidal hematoma projecting into the anterior mediastinum and displacing the trachea to the left. Rapid reversal of the coagulopathy was achieved with fresh frozen plasma and vitamin K. Consequently, the patient was managed conservatively with close observation, antibiotics, and steroids because no progression of airway compromise was manifested. Although the diagnosis can be easily established in these patients, no management guidelines of this condition exist. The potential of rapid airway compromise and the risk for exacerbation of bleeding in the light of significant elevation in the international normalized ratio (INR), make any airway management decisions very difficult. The importance of managing the airway and the haemostatic problem with the help of a multidisciplinary team is discussed.     

Pseudomembranous aspergillus tracheobronchitis superimposed on post-tuberculosis tracheal stenosis

Pseudomembranous aspergillus tracheobronchitis superimposed on post-tuberculosis tracheal stenosis has not been previously reported. In the patient described in this case report, the airway obstruction was worsened by aspergillus infection which responded to antifungal therapy and debridement of pseudomembranous tissues by rigid bronchoscopic procedures. A silicone stent was successfully placed in the trachea to restore airway patency when there was no more evidence of tracheobronchial aspergillosis. This case raises the questions of whether, how and when to restore airway patency in patients with tracheal stenosis and concurrent aspergillus tracheobronchitis.     

Bioabsorbable self-reinforced poly-L-lactide, metallic, and silicone stents in the management of experimental tracheal stenosis

The aim of the present study was to compare, in rabbits, the biocompatibility and suitability of a bioabsorbable spiral stent made of self-reinforced poly-L-lactide (SR-PLLA) in the management of experimental tracheal stenosis with stents made of metal and silicone. Tracheobronchial stenosis, and its management, is still problematic because stenoses are not always amenable to surgical resection and reconstruction, especially concerning anastomotic problems and stenosis after lung transplantation. Stenosis can be handled with stenting, although the ideal stent has yet to be developed; all the stents available have their disadvantages. Because stenting of the airways can be only temporary, stents made of bioabsorbable materials, theoretically, offer benefits. Tracheal stenosis was created in rabbits by the extramucosal resection of cartilaginous arches of the cervical trachea. After a few weeks, the animals were operated on again, and those stenoses that had developed were dilated with a balloon. Stents then were implanted in the area of stenosis to keep the dilated trachea open. All the animals in the group with silicone stents had to be killed because of respiratory difficulties: their stents had a tendency to occlude because of internal encrustation, and they developed a hyperplastic polyp at the ends of the stents. The SR-PLLA and metallic stents were tolerated well, and after follow-up ended the animals were put to death. This experimental study showed that silicone stents had a tendency to occlude and that stents made of metal and of SR-PLLA were well tolerated and can be used in the management of airway stenosis.     

支气管镜下高压球囊气道成形术的临床现状

气道为气体进出的通道,气道发生狭窄可导致一系列的临床症状。气道狭窄的病因很多,在西方发达国家,气道狭窄以气管一支气管肺癌、支气管袖式切除、肺移植、气管插管为主要原因,而在我国气管一支气管肺癌、气管结核、气管切开是导致气道狭窄的主要原因。随着介入性技术的不断发展,支气管镜下高压球囊扩张成形术已经成为治疗气道狭窄,特别是治疗良性气道狭窄的有效办法。本文对气道狭窄的病因及支气管镜下高压球囊扩张成形术治疗良性气道狭窄在临床的应用、适应证及疗效的评价进行如下综述。