Tracheal resection with end-to-end anastomosis for isolated postintubation cervical trachea stenosis: long-term results

Site of Tracheostomy and Its Influence on The Surgical Outcome and Quality of Life After Tracheal Resection and Anastomosis in Patients with Tracheal Stenosis

Introduction  With the advances in critical care, the incidence of post intubation tracheal stenosis is increasing. Tracheal resection and anastomosis have been the gold standard for the management of grades III and IV stenosis. Scientific evidence from the literature on the determining factors and outcomes of surgery is not well described. Objective  This study was aimed at determining the influence of tracheostoma site on the surgical outcomes and postoperative quality of life of patients undergoing tracheal resection anastomosis. Methods  Thirteen patients who underwent tracheal resection and anastomosis during a period of 3 years were followed up prospectively for 3 months to determine the degree of improvement in their quality of life postsurgery by comparing the pre and postoperative validated Tamil/vernacular version of RAND SF-36 scores and Medical Research Council (MRC) dyspnea score. Results  As per preoperative computed tomography (CT), the mean length of stenosis was found to be 1.5 cm while the mean length of trachea resected was 4.75 cm. We achieved a decannulation rate of 61.53%. There was an estimated loss of 3.20 +/- 1.90 cm of normal trachea from the lower border of the stenosis until the lower border of the stoma that was lost during resection. Analysis of SF-36 and MRC dyspnea scores revealed significant improvement in the domains of physical function postoperatively in comparison with the preoperative scores ( p  < 0.05). Conclusion  Diligent placement of tracheostomy in an emergency setting with respect to the stenotic segment plays a pivotal role in minimizing the length of the resected segment of normal trachea.

Reconstrucción de estenosis traqueal benigna: experiencia de un hospital de alta complejidad en Colombia

Introducción. La causa más común de estenosis laringotraqueal benigna es iatrogénica, secundaria a intubación orotraqueal. El manejo quirúrgico sigue siendo la alternativa que ha mostrado mejores resultados a largo plazo. El objetivo de este estudio fue analizar la experiencia en el manejo quirúrgico de la estenosis laringotraqueal durante 15 años en un hospital de alta complejidad en Colombia. Métodos. En este estudio se revisaron las historias clínicas de todos los pacientes tratados con reconstrucción de estenosis traqueal benigna, entre los años 2005 y 2020. Para el análisis estadístico se usaron métodos de estadística descriptiva, con análisis de frecuencias y medidas de tendencia central o de dispersión. Resultados. Se identificaron 38 pacientes con estenosis laringotraqueal, con un grado variable de estenosis. La nasofibrolaringoscopia fue bien tolerada y segura para determinar el grado y la longitud de la estenosis. El uso de tomografía sirvió para determinar la extensión y las características anatómicas. Los resultados del presente estudio son similares a los de la literatura en cuanto a complicaciones, mortalidad y falla de la anastomosis. Las complicaciones más frecuentemente reportadas son reestenosis, infección del sitio operatorio, lesión nerviosa y fístula, que en general se presentan en un tercio de los pacientes. Conclusiones. La experiencia de manejo quirúrgico de estenosis laringotraqueal en este hospital permite concluir que la reconstrucción traqueal es una opción segura en nuestro medio. Las tasas de éxito y de falla del tratamiento son equiparables a las reportadas en la literatura.

Perioperative outcomes after tracheoplasty: A NSQIP analysis 2014-2016

OBJECTIVES

Tracheoplasty or tracheal resection and are essential components of the care of patients with severe tracheal stenosis. We aimed to study the perioperative outcomes of patients after tracheoplasty or resection using a national surgical registry.

METHODS

We analyzed the 2014 to 2016 American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP) participant use file for patients who underwent tracheal resection or tracheoplasty (CPT codes 31750, 31760, 31780, and 31781). We analyzed the perioperative outcomes including length of stay (LOS), dehiscence, unplanned reintubations, unplanned surgeries, and 30-day readmission rates. A random 4:1 sample of non-tracheoplasty patients served as the control group.

RESULTS

From 2014 to 2016, 126 patients underwent tracheoplasty. The median age was 56 years (IQR = 45-63). There were 93 (74%) females, 88 (70%) white, and 3.2% (4/126) Hispanic. The median LOS was 7 days (IQR = 5-10 days). Of these, 4.8% (6/126) developed wound infections and 3/126 (2.4%) developed wound dehiscence. Five out of 126 required unplanned reintubation (4.0%) and 16/126 (13%) had an unplanned reoperation. The 30-day unplanned readmission rate was 16% (20/126). The wound infection, unplanned intubations, and readmission rates were significantly higher (P < .005) than the control group.

CONCLUSIONS

The 30-day perioperative outcomes of adult patients undergoing tracheoplasty showed that adverse events are common, but severe adverse events such as death are rare. Continued research into risk mitigation among these patients is warranted.

LEVEL OF EVIDENCE

NA Laryngoscope, 130:1514-1519, 2020.

Tracheal Stenosis: Evaluation of an Institutional Protocol and Introduction of Novel Surgical Criteria and Scoring System

Treatment modalities for treatment of post intubation and post tracheostomy tracheal stenosis are many. However, well defined surgical criteria and prognostic classification eluding us till date. A prospective study of 57 cases of post intubation and post tracheostomy tracheal stenosis managed as per well defined surgical criteria followed in our institution. Patients were divided into three groups as per the primary surgical procedure used. The stenosis was classified into mild, moderate and severe based on our proposed prognostic classification. The success rate of endoscopic procedure was 81% with average 1.6 number of procedures per patient, for tracheoplasty success rate was 63% with 1.4 number of procedure per patient, and similarly for tracheal resection and anastomosis was 90% with 1.1 procedure per patient. The patient score as per our proposed classification correlated well with the prognosis. Our surgical criteria correlates well with success rate reported by other authors and can be helpful for institutions or surgeons dealing with tracheal stenosis occasionally. Our prognostic classification can be used to predict prognosis.

The role of intraoperative nerve monitoring in tracheal surgery: 20-year experience with 110 cases

PURPOSE

To determine the utility of intraoperative nerve monitoring (IONM) during tracheal resection or slide tracheoplasty to prevent recurrent laryngeal nerve injury.

METHODS

110 patients underwent tracheal resection or tracheoplasty between 1997 and 2016. During the first 10-year period, IONM was not used while during the second 10-year period, IONM was used. 49 patients had surgery without IONM while 61 had surgery with IONM. During the post-operative period, patients with nerve injury were compared to determine if significant difference existed between the two modalities.

RESULTS

In patients who had surgery without IONM, 7 (14.2%) patients were found to have compromised nerve function whereas 8 (13.1%) patients in the group with IONM had nerve injury. 3 patients regained function in the first group while four regained function in the second. A Fisher's exact test was run on the entire cohort and the difference in vocal fold injury was not found to be statistically significant (p > 0.05).

CONCLUSION

Based on this single surgeon experience, there may be no protective benefit with the use of IONM during tracheal surgery.

Tissue-engineered tracheal reconstruction using mesenchymal stem cells seeded on a porcine cartilage powder scaffold

Tissue engineering using a biocompatible scaffold with various cells might be a solution for tracheal reconstruction. We investigated the plausibility of using mesenchymal stem cells (MSCs) seeded on a porcine cartilage powder (PCP) scaffold for tracheal defect repair. PCP made with minced and decellularized porcine articular cartilage was molded into a 5 × 12 mm (height × diameter) scaffold. MSCs from young rabbit bone marrow were expanded and cultured with the PCP scaffold. After 7 weeks culture, the tracheal implants were transplanted on a 5 × 10 mm tracheal defect in six rabbits. 6 and 10 weeks postoperatively, the implanted area was evaluated. None of the six rabbits showed any sign of respiratory distress. Endoscopic examination revealed that respiratory epithelium completely covered the regenerated trachea and there were no signs of collapse or blockage. A patent luminal contour of the trachea was observed on the computed tomography scan in all six rabbits and the reconstructed areas were not narrow compared to normal adjacent trachea. Histologic examination showed that neo-cartilage was successfully produced with minimal inflammation or granulation tissue. Ciliary beating frequency of the regenerated epithelium was not significantly different from the normal adjacent mucosa. MSCs cultured with a PCP scaffold successfully restored not only the shape but also the function of the trachea without any graft rejection.

Tissue-engineered tracheal reconstruction using chondrocyte seeded on a porcine cartilage-derived substance scaffold

OBJECTIVES

Tracheal reconstruction with tissue-engineering technique has come into the limelight in the realm of head and neck surgery. We intended to evaluate the plausibility of allogenic chondrocytes cultured with porcine cartilage-derived substance (PCS) scaffold for partial tracheal defect reconstruction.

METHODS

Powder made from crushed and decellularized porcine articular cartilage was formed as 5 mm × 12 mm (height × diameter) scaffold. Chondrocytes from rabbit articular cartilage were expanded and cultured with PCS scaffold. After 7 weeks culture, the scaffolds were implanted on a 5 mm × 10 mm artificial tracheal defect in six rabbits. Two, four and eight weeks postoperatively, the sites were evaluated endoscopically, radiologically, histologically and functionally.

RESULTS

None of the six rabbits showed any sign of respiratory distress. Endoscopic examination did not show any collapse or blockage of the reconstructed trachea and the defects were completely covered with regenerated respiratory epithelium. Computed tomography showed good luminal contour of trachea. Postoperative histologic data showed that the implanted chondrocyte successfully formed neo-cartilage with minimal inflammatory response and granulation tissue. Ciliary beat frequency of regenerated epithelium was similar to those of normal adjacent mucosa.

CONCLUSIONS

The shape and function of reconstructed trachea using allogenic chondrocytes cultured with PCS scaffold was restored successfully without any graft rejection.

Extended tracheal resections

There is no universally valid definition of the extent of tracheal resections that would be considered "extended." Underlying disease, necessary length of resection, anatomic localization, and chosen surgical approach account for a manifold interdependency. Existing data suggest a "cutoff margin" of 4 cm or more, referring to the likelihood of complications and necessity of additional mobilization maneuvers. This overview outlines worldwide experiences and the surgical variety of possibilities, as well as their execution and appropriate use.

Circumferential tracheal resection with primary anastomosis for post-intubation tracheal stenosis: study of 24 cases

The objective of this study is to evaluate the results of circumferential tracheal and cricotracheal resection with primary anastomosis for the treatment of post-intubation tracheal and cricotracheal stenosis. This is a retrospective analytical study. A total number of 24 patients were included in this study. The relevant preoperative, operative and postoperative records were collected and analyzed. Twenty patients were finally symptom-free reflecting an anastomosis success rate of 83.3 %. Variable grades of anastomotic restenosis occurred in 11 (45.8 %) patients, three patients were symptom-free and eight had airway obstructive symptoms. Four out of the eight patients with symptomatic restenosis were symptom-free with endoscopic dilatation while the remaining four patients required a permanent airway appliance (T-tube, tracheostomy) for the relief of airway obstruction and this group was considered as anastomotic failure. Cricoid involvement, associated cricoid resection and the type of anastomosis were the variables that had statistical impact on the occurrence of restenosis (P = 0.017, 0.017, 0.05; respectively). Tracheal resection with primary anastomosis is a safe effective treatment method for post-intubation tracheal stenosis in carefully selected patients. Restenosis does not always mean failure of the procedure since it may be successfully managed with endoscopic dilatation.

New technology applications: Knotless barbed suture for tracheal resection anastomosis

OBJECTIVES/HYPOTHESIS

Tracheal resection anastomoses are often under tension and can be technically challenging. New suture materials such as V-loc (barbed, knotless wound closure device) may offer advantages over conventional methods. The objective of this study is to determine if a running V-loc suture is of comparable tensile strength to conventional closure.

STUDY DESIGN

Laboratory based study of human cadaveric tissue.

METHODS

Fresh human cadaveric tracheas were dissected and incised into segments. Anastomosis of adjacent segments was then performed with either submucosal interrupted 3-0 Vicryl, or a running submucosal 3-0 V-loc suture. Anastomosed specimens were stretched to failure on an Instron force tension machine. Surgeon satisfaction was recorded by visual analog scale (VAS).

RESULTS

The tensile strength of 12 tracheal anastomoses was tested. Video documentation of V-loc suture technique and anastomosis failure was recorded. In both Vicryl (80%) and V-loc (100%) anastomoses, failure occurred at the membranous intercartilaginous region. In 20% of the Vicryl anastomoses, the suture was noted to break prior to tissue failure. Anastomoses with V-loc suture had equivalent failure force (mean, 59 N) compared to interrupted Vicryl (51 N), with P = .57. On VAS, surgeons were more satisfied with V-loc suture closure compared to interrupted Vicryl closure (paired t test, P = .003).

CONCLUSIONS

Tracheal anastomosis with running v-loc suture is a feasible alternative to conventional closure with interrupted Vicryl suture. V-loc suture provided a surgical advantage by improved ease of use.

Reconstruction of tracheal wall defect with a mesh patch of nickel-titanium shape-memory alloy

OBJECTIVES

We explored the feasibility of reconstructing tracheal wall defects with a mesh patch fashioned from a nickel-titanium shape-memory alloy.

METHODS

A tracheal wall defect was first constructed surgically by resecting the anterior half of the tracheal wall between the second and sixth tracheal rings. The defect was reconstructed in 8 experimental animals by replacing the resected tracheal mucosa and tracheal cartilage with a pedicle skin flap, which was then enclosed in the mesh patch. In 4 control animals, only a pedicle skin flap with strap muscles was used in the reconstruction procedure. The performance of the animals was observed after surgery. At the end of the experiments, the reconstructed segment was harvested for anatomic evaluation.

RESULTS

In the experimental group, 1 animal died 5 days after the operation. Endoscopic and anatomic examination of the 7 animals that survived the observation period showed that the reconstructed trachea was stable, with sufficient airway space for breathing. All 4 control animals died after the operation. After observing successful completion of this operation in animals, we successfully used this method to repair a tracheal wall defect in a human victim of a traffic accident.

CONCLUSIONS

Tracheal defects can be successfully reconstructed by use of a mesh patch of nickel-titanium shape-memory alloy as an extraluminal stent--a method that avoids complications associated with intraluminal stents.

Cervical tracheal resection with cricotracheal anastomosis: experience in adults with grade III–IV tracheal stenosis

Introduction:

Laryngotracheal stenosis is currently one of the most common complications associated with nasal and orotracheal intubation and tracheotomy. Once established, tracheal stenosis can be a complex and difficult problem to manage.

Patients and methods:

We retrospectively analysed 2004–2010 data for 12 male patients with postintubation cervical tracheal stenosis (grade III–IV) treated in the otolaryngology department, Mansoura University Hospitals. All patients had a tracheostomy at presentation, and all underwent tracheal resection with primary cricotracheal anastomosis and suprahyoid release.

Results:

Grade III stenosis was present in five patients (41.7 per cent) and grade IV stenosis in seven patients (58.3 per cent). The length of trachea resected ranged from 2 to 4 cm, representing one to four tracheal rings. In all 12 patients, the procedure allowed successful tracheotomy decannulation. Minor complications comprised surgical emphysema (n = 2) and wound infection (n = 1), and were managed conservatively. Major complications consisted of restenosis (n = 3), managed in two patients by repeated dilatation; one patient was lost to follow up.

Conclusion:

Segmental tracheal resection with cricotracheal anastomosis was successful in 11/12 (92 per cent) patients with severe cervical tracheal stenosis. The strategy for treatment of airway stenosis is now well established and success rates are high, with minimal or no sequelae.

[The systems of classification of laryngo-tracheal stenosis]

Laryngo-tracheal stenosis (LTS) is a relatively rare disease, which develops in very heterogenous group of patients. Careful diagnostics and classification are essential for planning the following treatment and assessing its results. To classify and treat LTS, endoscopic and imaging techniques are required. In this publication basing on the literature review different systems of LTS classifications are described in details. Additionally basing on our clinical experience the probe of choosing the best classification for Polish ENT and thoracosurgery departments was undertaken. In our opinion the use of complex grading systems is unreal in everyday work by Polish ENT surgeons and thoracosurgeons. We suggest to implement the Cotton's system and Medical Research Council dyspnea scale as the optimal way to classify and asses the outcomes of LTS treatment. The former system is well known and widely advocated in Poland, the latter requires a modicum of time from the physician. Both scales, as a combination of subjective and objective parameters show a strong correlation and therefore complement each other.

[Segmental tracheal resection for the treatment of tracheal stenoses]

BACKGROUND

Segmental tracheal resection is considered to be the standard treatment of tracheal stenoses.

MATERIALS/METHODS

During the time period 1985-2002, segmental tracheal resection with a primary end-to-end anastomosis was performed in 117 patients with a cervical or upper thoracal stenosis of the trachea. The age distribution of the patients was between 7 and 77 years. Of the patients with a benign tracheal stenosis, sufficient data for a retrospective analysis were available in 101 patients. The length of the resected tracheal segments varied between 2 and 6 cm which required mobilisation of the trachea and the larynx and, if necessary, incision of the pulmonary ligament.

RESULTS

In 5 patients a permanent damage of the recurrent laryngeal nerve was seen, of which 4 had undergone revision surgery and 10 months after surgery 93% presented with a large and stable tracheal lumen without any relevant restenosis. Due to a restenosis of 70-80% causing dyspnea at rest, 3% of the 101 patients had to undergo revision surgery. In 4% a mild and asymptomatic restenosis of 30-40% was seen which did not require any further treatment.

CONCLUSION

These results demonstrate that segmental tracheal resection can safely and effectively remove stenotic tracheal segments of up to 6 cm and is therefore the treatment of choice.

Does successful segmental tracheal resection require releasing maneuvers?

OBJECTIVES

Tracheal resection is a well-established option for the management of airway stenosis. Releasing maneuvers have been described to reduce anastomotic tension. The aim of this study is to report on a series of tracheal resections performed without the use of these maneuvers.

STUDY DESIGN

Retrospective chart review.

SETTING

Tertiary hospital.

METHODS

All patients undergoing tracheal resection by the first author over a 6-year period were reviewed.

RESULTS

Patients (n = 17; 7 men and 10 women, ages 23-76) were managed with tracheal resection and anastomosis without stenting or postoperative tracheotomy. 16/17 (94%) patients had successful treatment of their stenosis. 1/17 (6%) failed and 1/17 (6%) required dilation. There was no postoperative swallowing dysfunction.

CONCLUSIONS

Segmental tracheal resection without releasing maneuvers was successful in 16/17 (94%) patients.

SIGNIFICANCE

Though extrapolation from this series may be limited, future practitioners may consider forgoing additional releasing maneuvers for tracheal resection in many cases.

Dilatation for Assisted Ventilation-Induced Laryngotracheal Stenosis

OBJECTIVE

To assess the long-term results of dilatation and our experience with dilatation for assisted ventilation-induced laryngotracheal stenosis.

DESIGN

A retrospective study of 32 patients primarily treated with dilatation for assisted ventilation-induced laryngotracheal stenosis between 1977 and 2002.

SETTING

A tertiary care center and university teaching hospital.

PATIENTS

There were 19 men and 13 women aged 15 to 76 years. The stenosis was cicatricial with some inflammatory process in 27 patients and completely mature in 5 patients. The stenosis involved the cricoid and the trachea in four patients. In 28 patients, the stenosis involved only the trachea.

METHODS

Dilatation was performed with serially sized rigid bronchoscopes. Endoscopic laser vaporization was never performed in this series. Six patients were treated with only one dilatation. The 26 remaining patients were treated with successively 2 to 10 dilatations (mean, 3.3 dilatations). The dilatation success rate was analyzed using the Kaplan-Meier method.

RESULTS

Median duration of follow-up was 1.8 years. Mortality rate was 9.4%. The overall failure rate was 71.8%. Twenty patients presented with recurrent stenosis. The treatment of recurrent stenosis consisted of tracheal resection with end-to-end anastomosis (11 patients, 55%), cricotracheal anastomosis (5 patients, 25%), tracheal endoprosthesis (2 patients, 10%), and tracheotomy (1 patient, 5%). All patients who underwent tracheal or cricotracheal anastomosis were successfully treated. None of the variables under analysis (sex, age, medical history, cause for intubation, intubation type and duration, delay from initial injury, degree of stenosis, length of trachea involved, number of dilatations) were statistically related to the incidence of complications and the success rate of dilatations.

CONCLUSIONS

We do not recommend dilatation technique as the sole treatment for assisted ventilation-induced laryngotracheal stenosis. This technique is helpful in case of emergency to restore an airway and useful for the assessment of stenosis.

Tracheal resection with end-to-end anastomosis for benign tracheal stenosis

To review our experience with tracheal resection with end-to-end anastomosis for tracheal stenosis, we performed a retrospective review at a tertiary-care academic medical center. Twenty-eight patients underwent circumferential tracheal resection with end-to-end anastomosis by 2 attending otolaryngologists from 1989 to 2002. Patients were excluded if they were under 12 years of age or if the surgical indication was tracheal or thyroid neoplasm. The indications for tracheal resection were postintubation stenosis (n = 9; 32%), posttracheotomy stenosis (n = 7; 25%), both postintubation and posttracheotomy stenosis (n = 9; 32%), external tracheal trauma (n = 2; 7%), and presence of a foreign body (n = 1; 4%). Two to 8 rings were resected. The follow-up periods ranged from 18 months to 13.5 years. The anastomotic success rate was 89% (n = 25). No patients died as a result of the procedure. We conclude that tracheal resection with end-to-end anastomosis is a relatively safe and reliable procedure for the treatment of tracheal stenosis in appropriately selected patients.

Prise en charge chirurgicale et/ou endoscopique des sténoses trachéales acquises non tumorales de l’adulte

OBJECTIVES

Retrospective survey (over 13 Years) of the surgical treatment of 46 acquired tracheal stenosis, in adult patients. Our goals were to study their epidemiology, changes in the surgical technique with the cervical or endoscopic approach, and the recent contribution of endoprotheses.

MATERIALS AND METHODS

Sixty-six therapeutic procedures were performed for 46 tracheal stenoses. Most of stenoses were post-intubation and/or post-tracheotomy and were fixed in 50% of the cases. We used 21 sleeve resections with end-to-end anastomoses, 9 tracheal stents, 27 dilations, 6 calibrations, and 3 electro-coagulations.

RESULTS

The sleeve resection gave 91% success (1 failure and 1 death). The endoscopic treatments were less efficient: 79% for tracheal stents (2 mobilizations), 50% success for iterative dilations. The respiratory tests were meaningfully improved with a mean follow-up of 18 Months.

CONCLUSION

Sleeve resection remains the gold standard treatment. For all temporary or definitive contraindications to open surgery, tracheal stents would be an excellent alternative to avoid often inefficient iterative dilations.

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.

Reinforcement of an end-to-end Tracheal Resection Anastomosis with Fibrin Glue: A Case Report

Tracheal resection and primary anastomosis is the treatment of choice for a short-segment stenosis. However, the procedure does carry the risk of two potentially fatal complications: anastomosis breakdown and leak. We describe the case of a 67-year-old man who was treated for a 3-cm tracheal stenosis secondary to a prolonged intubation and multiple tracheostomies. The patient underwent a tracheal resection and primary anastomosis. The anastomosis was reinforced with fibrin sealant, which created an airtight seal. The patient was extubated postoperatively, and he healed without complication. Fibrin sealant is a convenient, safe, and effective material for reinforcing anastomotic suture lines.

Laryngotracheal Anastomosis: Primary and Revised Procedures

OBJECTIVES

Acquired upper airway stenosis is usually associated with a complex of pathological conditions at the high tracheal and the subglottic levels. Reported reconstructive techniques include widening by incorporation of grafts, segmental resection, and anastomosis or combined procedures. The management of recurrent stenosis after reconstructive surgery is a major challenge and has rarely been discussed in the literature. The purposes of the present study are to compare the clinical course of primary versus revised reconstructive procedures and to analyze the effect of age, diabetes, chronic lung disease, grading of stenosis, extent of resection, and revised procedures on the operative rate of success.

STUDY DESIGN

A cohort study in a tertiary referral medical center.

METHODS

The clinical course of 23 consecutive patients undergoing laryngotracheal anastomosis was studied comparing a group of 13 primary with 10 revision procedures. Seventeen patients underwent cricotracheal and six patients thyrotracheal anastomoses. All patients but one were tracheotomized before the definitive reconstructive procedure. Suprahyoid release was routinely performed except for two cases, and only one patient required sternotomy. The Wilcoxon test was used to examine the relationship between preoperative clinical parameters and the postoperative success (i.e., airway patency).

RESULTS

Twenty-two of 23 patients (95.6%) had successful decannulation. Four patients required a revision procedure because of repeat stenosis at the site of the anastomosis (2) or distal tracheal malacia (2). Residual airway stenosis of less than 50% was noted in six patients, although only three complained of dyspnea during daily-activity exertion. There was no associated mortality. Complications included subcutaneous emphysema (4), granulation tissue formation (3), pneumonia (2), cardiac arrhythmia (2), and one each of pneumomediastinum, neck hematoma, and urosepsis. Protracted aspirations were noted in one patient who had revision surgery. Age was the only parameter that correlated with postoperative airway patency (P <.07), whereas the presence of chronic obstructive lung disease and diabetes, grade of stenosis, type of surgery, and revision surgery were found to be insignificant.

CONCLUSIONS

The clinical course of laryngotracheal anastomosis in primary and revised procedures was similar in our group of patients. The operation can be performed safely, with an expected high rate of success and acceptable morbidity.

Laryngeal mask airway and high-frequency jet ventilation for the resection of a high-grade upper tracheal stenosis

The surgical resection of a high-grade tracheal stenosis presents a special case of a difficult airway. A 20-year-old male was treated for a 45-mm long tracheal stenosis with 60% reduction of the patent airway area beginning 25 mm below the glottis. To avoid manipulations of the affected segment before surgical exposure of the trachea was established, strictly supraglottic ventilation via a laryngeal mask airway was performed. During removal of the stenosis and creation of the anastomosis, transglottic high-frequency jet ventilation (HFJV) is a convenient technique that enables optimal access to the operation field. Changing from HFJV to conventional ventilation after completion of the anastomosis is not necessary, and the jet catheter can be left in place until the end of the anesthesia.