Partial cricotracheal resection for severe upper tracheal stenosis: Potential impacts on the outcome

Revision tracheal resection anastomosis for recurrent stenosis after airway surgeries: functional outcomes

OBJECTIVES

To evaluate the surgical and functional outcomes as well as the quality of life among patients who underwent revision tracheal/cricotracheal resection anastomosis for recurrent stenosis after previous unsuccessful airway surgeries.

METHODS

This prospective study was conducted on 53 patients. Circumferential resection of the stenotic airway segment was done with primary end-to-end anastomosis. All surgeries were performed by the authors of this work with the same standardized surgical techniques. To decrease the anastomotic tension, suprahyoid release was performed for all patients and trachea-hyoid detensioning stitches were placed. Surgiflo was applied over the line of the anastomosis to enhance healing. Surgical and functional outcomes were evaluated.

RESULTS

Types of anastomosis were cricotracheal anastomosis (n = 18), thyrotracheal anastomosis (n = 24), and tracheo-tracheal anastomosis (n = 11) according to the remaining proximal and distal stumps. The overall decannulation rate was 92.5% (49 out of 53 patients). No major intraoperative complications were reported. Postoperative complications were reported in 13 patients (24.5%), in the form of restenosis (n = 7), granulation tissue formation at the site of anastomosis (n = 5), surgical emphysema / minor air leak through drains (n = 4), unilateral vocal fold paralysis (n = 2), wound seroma (n = 1). Regarding functional outcomes, dyspnea was considerably alleviated both at rest and during exercise, and most patients had satisfactory voice and swallowing related functions. The majority of patients reported adequate QOL.

CONCLUSION

Revision tracheal/cricotracheal resection anastomosis presents significant surgical challenges. Nevertheless, by employing meticulous surgical techniques and implementing strategies to reduce anastomotic tension and enhance healing such as suprahyoid release, trachea-hyoid detensioning stitches, and the application of surgiflo, high success rates and satisfactory functional outcomes were achieved.

Tracheal resection anastomosis for rare tracheal inflammatory lesions mimicking malignancy: report of 2 cases

BACKGROUND

Tumor-like lesions of the trachea are rare and challenging in diagnosis and management. Inflammatory myofibroblastoma, also known as Inflammatory pseudo tumors (IPTs), as well as Rosai Dorfman Disease (RDD) are inflammatory lesions that may involve the central airways with variable non-specific clinical features mimicking tumors.

CASE PRESENTATION

In this study 2 cases with tumor-like lesions are presented. One case with an inflammatory pseudotumor and the other one with Rosai-Dorfman disease affecting the upper trachea. Both cases were successfully managed with tracheal resection anastomosis.

CONCLUSION

Tracheal Inflammatory myofibroblastoma, and Rosai-Dorfman diseases are rare tumor like lesions that present with upper airway obstruction. Despite being benign, these lesions may have features suggestive of malignancy, requiring prompt management. Complete surgical excision by segmental resection and primary anastomosis (if feasible) is the treatment of choice with an optimum outcome.

Revision cricotracheal resection: our experience

OBJECTIVE

The incidence of recurrent stenosis after cricotracheal resection is 3-9.5 per cent. Management of such patients is challenging. This study aimed to review our experience in revision cricotracheal resection.

METHODS

The study was conducted in the Otorhinolaryngology Department, Mansoura University Hospitals, Egypt, on nine patients with recurrent stenosis following cricotracheal resection. Revision cricotracheal resection was performed in all patients. Surgiflo was applied on the site of anastomosis to enhance healing.

RESULTS

No intra-operative complications were recorded. Minor post-operative complications occurred in two patients (surgical emphysema and temporary choking); no major complications were reported. Re-stenosis occurred in one patient. Successful decannulation was achieved in eight of the nine patients.

CONCLUSION

Revision cricotracheal resection is the definitive curative treatment for recurrent stenosis after previous unsuccessful resection. It has high success rates, provided that careful pre-operative assessment and meticulous operative technique are performed.

Superior Strategy in Benign Tracheal Stenosis Treatment: Surgery or Endoscopy?

INTRODUCTION

 Due to the variations in (laryngeal) tracheal stenosis (TS) patient groups, there is still no consensus on which patient should be treated with endoscopy or surgery. The aim of the present study was to generate an algorithm in the light of the related literature and the data obtained from a clinic where both endoscopic and surgical treatments are conducted.

METHOD

 A retrospective analysis was performed on the data of a total of 56 patients during 2013 to 2019. A total of 38 patients were subject to surgery with 31 as a first treatment option and 7 due to the unsatisfactory results of endoscopic treatments. Endoscopic approaches were tried on a total of 29 patients with 25 as initial treatment and 4 due to postsurgical recurrence.

RESULTS

 Symptomatic full control ratio was determined as 69% with endoscopic treatments, 89.5% in subglottic stenosis (SGS) surgery (n = 19), and 89.5% in trachea surgery (n = 19). However, success rates with no recurrence were determined, respectively, as 40.0, 36.4, and 36.4% for patients subject to dilatation, stent, or T tube treatment. Dilatation was observed to be successful in patients with stenotic segment lengths of less than 1.5 cm (p = 0.02). Failure rates increased in SGS (p = 0.03) and TS (p = 0.12) in the surgical group with increasing stenotic segment length. The presence of comorbidities was not effective on treatment success.

CONCLUSION

 Endoscopic methods are preferred in cases of web-like stenosis. Surgical methods should first be considered for other patients and endoscopic methods should be used on patients who are not suited for surgery or in cases of postsurgical recurrence.

Challenging tracheal resection anastomosis: Case series

OBJECTIVES

This study was conducted to review our experience in Otorhinolaryngology Department, Mansoura University Hospitals, Egypt, in the last 2 years in the management of high-risk patients who underwent cricotracheal resection due to different pathologies.

METHODS

This case series included nine patients with severe, grade III or IV subglottic / cervical tracheal stenosis. These patients were considered high risk patients due to unusual pathology / etiology of stenosis or associated surgical field morbidity. Four patients had recurrent stenosis after previous unsuccessful cricotracheal resection, three patients had subglottic stenosis due to external neck trauma which compromised the surgical field. One patient had upper tracheal neoplasm, and in 1 patient there was upper tracheal stenosis associated with tracheo-esophageal fistula.

RESULTS

Successful decannulation was achieved in all patients (n = 9) without any reported major intraoperative or postoperative compilations.

CONCLUSION

Cases of subglottic / upper tracheal stenosis due to uncommon pathologies like neoplastic lesions, external neck trauma compromising the surgical field and revision cricotracheal resection, can be successfully managed by cricotracheal resection. However, a highly skilled team, well familiar with these surgeries, is mandatory to achieve an optimum outcome.

Effect of resected length in reconstructive surgery for tracheobronchial injury

Background

Mechanical injury to the trachea and bronchi may cause mild to severe stenosis requiring surgical intervention for reconstructing the damaged trachea. The location, length, and cause of injury are important factors affecting the surgical outcome.

Method

We conducted a retrospective study to evaluate the results of reconstructive surgery on noncancerous tracheobronchial lesions in 75 patients aged 5–55 years who had undergone reconstructive tracheobronchial surgery in our hospital from 2009 to 2018.

Results

The causes of tracheobronchial injury included blunt trauma in 38 patients, sharp penetrating trauma in 24, a postintubation lesion in 6, a post-tracheotomy lesion in 3, tuberculosis in 3, and an adult congenital lesion in one. In 59 cases of a lesion in the trachea, the length of missing segment before reconnection was 1–2 cm in 6 cases, 3 cm in 22, 4 cm in 18, 5 cm in 13, and >5.5 cm in 1 case. The length of the resected segment was <5.5 cm in all survivors, whereas one death occurred when the resected length was approximately 6 cm.

Conclusions

The length of the resected segment and precision of the surgery are crucial for determining the outcome of surgery.

Effect of mitomycin-C applied through different approaches following tracheal surgery on development of granulation tissue and level of nephrotoxicity in rats

Background

This study aims to evaluate the effect of mitomycin-C applied through different drug administration approaches on the development of granulation tissue in the field of surgery and renal functions in rats which underwent tracheal surgery.

Methods

Fifty male adult Sprague Dawley rats (weighing mean 200 g to 300 g) were divided into five groups. An incision was performed between the fifth and sixth cartilage ring of the trachea in all groups under anesthesia and the incision was primarily repaired with a 6/0 monofilament absorbable suture. A single dose of mitomycin-C 0.5 mg was applied in the experimental animals appropriate with their assigned groups as topical, intraperitoneal injection, injection to the wound edges, and through inhalation. No mitomycin-C was administered in one group which was accepted as the control group. Rats were sacrificed four weeks after surgery and their tracheas were excised subsequently. Tracheal tissue samples were histopathologically evaluated in terms of epithelization, fibrosis, amount of fibroblasts, angiogenesis, and inflammatory response. Diameter and wall thickness of the tracheas were measured. Blood urea and creatinine levels were evaluated for nephrotoxicity, and the rats were immunohistochemically examined for glomerular pathology.

Results

Epithelization was statistically significantly decelerated (p<0.01), diameter of the trachea was statistically significantly larger (p<0.05), and wall thickness of the trachea was significantly thicker in the group with topical mitomycin-C application compared to the control group (p<0.01).

Conclusion

Topically applied mitomycin-C following tracheal surgery slows down epithelization and, thus, decreases the development of granulation tissue and maintains a wider diameter of the trachea.

Functional outcome after (laryngo)tracheal resection and reconstruction for acquired benign (laryngo)tracheal stenosis

Background

In this study we focus on functional outcomes after (laryngo)tracheal resection and reconstruction for acquired benign (laryngo)tracheal stenosis, with a specific interest in the impact of laryngeal involvement on postoperative outcome.

Methods

All patients who underwent (laryngo)tracheal surgery for benign pathology between 1996 and 2017 in our centre were included in this retrospective study. Surgical outcomes were procedural success rate, and airway- and voice-related complications. Functional results were assessed using (standardized) questionnaires for quality of life, sensation of dyspnea, swallowing function, and voice perception.

Results

Of 119 consecutive patients, 47 underwent laryngotracheal resection and reconstruction and 72 underwent segmental tracheal surgery (78% with an end-to-end tracheal anastomosis and 22% with a cricotracheal anastomosis). Overall success rate was 92% and was similar for all groups, with an overall significant improvement in quality of life when compared to the preoperative situation. However, after laryngotracheal surgery, airway-related complications were more common when compared to segmental resections with an end-to-end tracheal anastomosis (30% versus 7%, P=0.003). Additionally, early voice alterations without recurrent nerve palsy were reported twice as often (34% versus 16%, P=0.034) and voice quality experienced during follow-up was significantly worse when compared to segmental resections. Overall response rate to the questionnaires on functional outcome was 63%.

Conclusions

(Laryngo)tracheal surgery is safe and beneficial, with significant functional improvement during mid- and long-term follow-up. However, laryngeal involvement is a predictor for increased surgical airway-related complications. Additionally, voice alterations without recurrent nerve palsy are far more common after laryngotracheal resection and are a serious handicap. This aspect is underexposed in current literature and deserves further attention during preoperative counseling and patient follow-up. However, the results on functional outcome of this current study should be interpreted with caution due to the somewhat low response rate of the questionnaires.