Surgical outcomes of post intubational or post tracheostomy tracheal stenosis: report of 18 cases in single institution

Cricotracheostomy in a patient with severe kyphosis: A case report

Cricotracheostomy is a useful surgical procedure for opening the airway in cases where conventional tracheotomy is difficult. This is a safe and easy technique involving removal of the anterior portion of the cricoid cartilage. Herein, we report the case of a patient with difficulty in neck extension due to severe kyphosis, who underwent cricotracheostomy. A 65-year-old woman developed dyspnea and was transported to our hospital. SpO2 was 60% (room air) and endotracheal intubation was performed. She was managed on ventilator. However, weaning off the ventilator was difficult, and endotracheal intubation was prolonged. Subsequently, the patient was referred to us for a tracheostomy. The patient was unable to maintain the supine position due to severe kyphosis, and computed tomography revealed that the brachiocephalic artery was running just below the thyroid gland. Therefore, conventional tracheostomy was difficult to perform, and we performed cricotracheostomy instead. After the cricotracheostomy, there were no tracheal problems, such as tracheal stenosis and stomal hemorrhage. Cricotracheostomy can be performed in cases where multiple anatomical difficulties may be faced in the tracheostomy site, as in this case. Furthermore, cricotracheostomy is beneficial for long-term airway management because it causes fewer complications compared to conventional tracheotomy.

Surgical treatment of severe benign tracheal stenosis

OBJECTIVE

To present clinical experiences regarding surgical treatment of patients with severe cicatricial tracheal stenosis.

PATIENTS AND METHODS

From January 2008 to March 2020, 14 patients underwent tracheal resection and reconstruction under general anesthesia. Nine cases had cervical tracheal stenosis and five cases had thoracic tracheal stenosis. The mean diameter and length of strictured trachea was 0 - 8 mm with a mean of 4.5 ± 2.4 mm and 1 - 3 cm with a mean of 1.67 ± 0.63 cm, respectively. General anesthesia and mechanical ventilation were performed in ten cases and four patients underwent femoral arteriovenous bypass surgery due to severe stenosis. End-to-end anastomosis of trachea was performed in 13 cases and the anastomosis between trachea and cricothyroid membrane was performed in one case. Absorbable and unabsorbable sutures were used for the anterior and posterior anastomoses, respectively. Postoperative neck anteflexion was maintained by a suture between the chin and superior chest wall. The relevant data of the 14 patients were retrospectively reviewed, and the operation time, blood loss, postoperative hospital stay, postoperative complications and follow-up were retrieved.

RESULTS

There was no intraoperative death. The length of resected trachea ranged from 1.5 to 4.5 cm with a mean of 1.67 ± 0.63 cm. Operation time ranged from 50 - 450 min with a mean of 142.8 ± 96.6 min and intraoperative hemorrhage ranged from 10 - 300 ml with a mean of 87.8 ± 83.6 ml. Follow-up period ranged from 5 to 43 months with a mean of 17.9 ± 10.6 months. None of the patients had recurrent laryngeal nerve paralysis during postoperative follow-up. Ten cases were discharged uneventfully. Anastomosis stenosis occurred in three cases who received interventional therapies. Bronchopleurocutaneous fistula occurred in one patient after 6 days postoperatively and further treatment was declined.

CONCLUSION

The strategies of anesthesia, mechanical ventilation, identification of stenosis lesion, the "hybrid" sutures and postoperative anteflexion are critical to be optimized for successful postoperative recovery.

Two cases with postintubation tracheal stenosis after COVID-19 pneumonia

Only a small percent of all intubated SARS-CoV-2-positive patients survive because of the development of severe respiratory and multiorgan failure. The development of tracheal stenosis after orotracheal intubation or tracheostomy is a dangerous complication with gross consequences for the patient and medical staff. Endoscopic interventional procedures could be used in simple tracheal stenosis and surgical resection and anastomosis are reserved for complex stenosis or after unsuccessful endoscopic treatment. We present two cases with tracheal stenosis as a complication of prolonged intubation in COVID-19 survivors which was diagnosed up to 6 months after discharge. Clinical management and surgical techniques are also discussed.

Establishment of two canine models of benign airway stenosis and the effect of mitomycin C on airway stenosis

OBJECTIVES

Cuffed endotracheal intubation and stent implantation were employed to simulate two types of benign airway stenosis and further to analysis the different features between them from trachecscopic characteristics, gross anatomy to histopathological changes. In addition, our study explored the therapeutic effect of mitomycin C at different concentrations on granulation tissue caused by stent implantation in order to provide a new therapeutic strategy for clinical treatment of benign airway stenosis.

METHODS

Twelve beagle dogs were randomly divided into four groups, with three dogs in each group. Group A: Three beagle dogs were intubated through oral trachea after general anesthesia and cuff pressure maintained at 200 mmHg for 24 h. Group B, Group C and Group D: endotracheal coated self-expanding metal stents were placed after general anesthesia under the guidance of bronchoscope. On the Day7 after stent implantation, Group B, as control group, was injected phosphate buffer solution of 1 ml into granulation tissue at the end of stent; Group C was injected mitomycin C of 1 ml at 0.4 mg/ml and Group D was injected mitomycin C of 1 ml at 0.8 mg/ml into granulation tissue at the end of metal airway stent respectively, the same method as Group B. Bronchoscopy was used to observe tracheal lumen on the seventh day, fourteenth day and twenty-first day after modeling and pathological changes were examined on twenty-first day.

RESULTS

Two models of benign airway stenosis can be established by cuffed endotracheal intubation and stent implantation. There was tracheal rupture in the trachea cartiage ring in the cuffed endotracheal intubation group, but was't in stent implantation group. Histopathological characteristics were different between cuffed endotracheal intubation and stent implantation groups. In stent placement groups, we found that the stenosis degree of mitomycin C at 0.4 mg/ml was approximately 19%-32%, mitomycin C at 0.8 mg/ml was approximately 16%-21% and the control group was approximately 36%-47%.

CONCLUSION

The two models of canine benign tracheal stenosis induced by cuffed endotracheal intubation and stent implantation are relatively simple, reliable and reproducible and have different characteristics. Mitomycin C could inhibit proliferation of granulation tissue and attenuate the degree of airway stenosis caused by stent implantation.

Management of a Patient With Tracheal Stenosis After Previous Tracheotomy

Tracheal stenosis after tracheotomy can cause difficult airway management and respiratory complications. It is difficult to predict tracheal stenosis after tracheotomy based on a patient's symptoms as the symptoms of tracheal stenosis appear only after they become severe. In patients with a history of previous tracheotomy, it is important to consider the risk factors for tracheal stenosis. Detailed preoperative evaluation of patients with a history of previous tracheotomy is essential and should include 3-dimensional assessment of the airway. We report the preoperative assessment and perioperative management of an 83-year-old woman at high risk for tracheal stenosis due to a previous emergency tracheotomy who was scheduled to undergo general anesthesia for a right maxillectomy for squamous cell carcinoma. Preoperative anteroposterior chest radiograph revealed findings indicative of tracheal stenosis. Additional detailed examinations of the stenotic area were conducted with computed tomography imaging and bronchofiberscopy. General anesthesia with nasotracheal intubation was performed, and although there were no adverse intraoperative events, stridor after extubation was observed. Nebulized epinephrine was administered via an ultrasound nebulizer and effectively improved the patient's postoperative transient dyspnea.

Anesthetic consideration for airway management in patient undergoing tracheal resection and reconstruction for severe postintubation tracheal stenosis: a case report

Introduction Severe postintubation tracheal stenosis (PITS) is a rare iatrogenic complication after endotracheal intubation.Case presentation A case of PITS in a 51-year-old male undergoing partial pericardiectomy with a principal diagnosis of tuberculous constrictive pericarditis. Within 6 hours of extubation, a second emergency intubation lasting 120 hours was performed. The patient reported exertional dyspnea 30 days after discharge. High-resolution tracheobronchial tree computed tomography with three-dimensional reconstruction revealed constriction of the tracheal lumen of more than 80% at the thyroid planar upper third of the trachea. Flexible bronchoscopy revealed a tracheal stenosis located 3-4 cm from the glottis that could not be passed prior to general anesthesia. Mechanical ventilation with a ProSeal laryngeal mask airway (PLMA) and preparation for extracorporeal circulation as a final rescue option were performed to maximize patient safety. The patient underwent a tracheal resection and reconstruction without complications.Conclusion A supraglottic airway mode may be a practical and worthwhile alternative for patients with severe PITS.

Long-term efficacy and safety of the Dumon stent for benign tracheal stenosis: a meta-analysis

BACKGROUND

The short-term efficacy of Dumon stent has been well demonstrated. Across years, however, due to insufficient sample size and absent of the randomized controlled trial, no reliable conclusion could be reach for Dumon stent's long-term efficacy. So, we conducted the first meta-analysis to evaluate the long-term efficacy and safety of the Dumon stent for benign tracheal stenosis.

METHODS

Data on related trials were obtained by doing a literature search in PubMed, Web of Science and Cochrane Library. Random-effect and fixed-effect models were used to calculate the efficacy and incidence of complication of Dumon stent placement.

RESULTS

A total of 395 patients from 8 studies were included in this study, revealing that the stability rate was 41.12% (95% CI, 34.85-48.52%) of Dumon stenting. Further, a curative rate of 40.74% (95% CI, 34.92-47.53%), and efficacy of 75.49% (95% CI, 70.89-80.39%) were obtained from this study. Analysis of the incidence of complications indicated 25.04% of migration (95% CI, 17.52-35.79%), 15.66% granulation (95% CI, 9.39-26.11%) and 23.82% of mucus retention 23.82% (95% CI, 13.77-41.20%).

CONCLUSIONS

Dumon stent has a moderate efficacy for treating benign tracheal stenosis with approximately 20% incidence of complication, regular bronchoscopy follow-up should be conducted. Thus, further research is required to modified Dumon stenting.

Tracheal Reconstruction Surgery Supported by Extracorporeal Membrane Oxygenation for Patients with Traumatic Post-Tracheotomy Tracheal Stenosis

PURPOSES

Patients who require surgeries for traumatic post-tracheotomy tracheal stenosis (PTTS) often cannot be supported using conventional airway management approaches. This study documents the use of extracorporeal membrane oxygenation (ECMO) in patients with PTTS.

METHODS

Patient characteristics, procedure, and outcome of patients who required tracheal reconstruction surgery for PTTS supported by ECMO were retrieved and analyzed.

RESULTS

Four patients (mean age 28 years; range 17-48 years) with traumatic PTTS underwent tracheal reconstruction surgery supported by ECMO. The mean time from removal of tracheotomy tube to admission was 3.2 months (range: 1-9 months). The mean diameter of the stenotic segment was 5 mm (range: 4-6 mm). One patient underwent tracheoplasty and semi-tracheostomy with venoarterial ECMO urgently. Three patients underwent tracheal resection and end-to-end anastomosis (TRE) with venovenous ECMO empirically. Intervention success was achieved in 100% (4/4) of patients. The mean duration of ECMO was 35.3 hours (range: 16-53 hours). The overall survival rate was 100% (4/4) within a mean follow-up of 26 months (range: 7-57 months).

CONCLUSIONS

ECMO is a safe and feasible method to support oxygenation for patients with critical traumatic PTTS during tracheal reconstruction surgery.

Bioinformatics analysis and verification of gene targets for benign tracheal stenosis

Background

Tracheal injury could cause intratracheal scar hyperplasia which in turn causes benign tracheal stenosis (TS). With the increasing use of mechanical ventilation and ventilator, the incidence of TS is increasing. However, the molecular mechanisms of TS have not been elucidated. It is significant to further explore the molecular mechanisms of TS.

Methods

The repeatability of public data was verified. Differently expressed genes (DEGs) and most significant genes were identified between TS and normal samples. Enrichment analysis of Gene Ontology (GO) and Kyoto Encyclopedia of Genes and Genomes (KEGG) were analyzed. The comparative toxicogenomics database were analyzed. TS patients were recruited and RT‐qPCR were performed to verify the most significant genes.

Results

There exist strong correlations among samples of TS and normal group. There was a total of 194 DEGs, including 61 downregulated DEGs and 133 upregulated DEGs. GO were significantly enriched in mitotic nuclear division, cell cycle, and cell division. Analysis of KEGG indicated that the top pathways were cell cycle, and p53 pathway. MKI67(OMIM:176741), CCNB1(OMIM:123836), and CCNB2(OMIM:602755) were identified as the most significant genes of TS, and validated by the clinical samples.

Conclusion

Bioinformatics methods might be useful method to explore the mechanisms of TS. In addition, MKI67, CCNB1, and CCNB2 might be the most significant genes of TS.

Combined Tracheal Resection and Coronary Artery Bypass With ECMO Support

In patients with critical tracheal stenosis, extracorporeal membrane oxygenation support provides an additional level of safety over conventional approaches to secure an airway. This brings operations with exquisite complexity into the realm of routine feasibility. Here we describe a case of combined tracheal resection with 4-vessel coronary artery bypass grafting in a patient with critical tracheal stenosis, occluded coronary arteries, and severely reduced ejection fraction. Postoperatively, the patient made an excellent recovery. This case exemplifies a trend where multidisciplinary cooperation, refinements in surgical techniques, and technological advances allow ever more complex cardiothoracic operations to be performed safely.

Erythromycin combined with corticosteroid reduced inflammation and modified trauma-induced tracheal stenosis in a rabbit model

Background:

Patients with endotracheal intubation or tracheostomy are subject to benign tracheal stenosis (TS), for which current therapies are unsatisfactory. We conducted a preliminary investigation of drugs and drug combinations for the prevention and treatment of TS in a rabbit model.

Methods:

Fifty-four rabbits were apportioned into nine groups according to treatment: sham-operated control; untreated TS model; amikacin; budesonide; erythromycin; penicillin; amikacin + budesonide; erythromycin + budesonide; and penicillin + budesonide. TS was induced by abrasion during surgery. The drugs were applied for 7 days before and 10 days after the surgery. Rabbits were killed on the eleventh day. Tracheal specimens were processed for determining alterations in the thicknesses of tracheal epithelium and lamina propria via hematoxylin and eosin. The tracheal mRNA (assessed by real-time quantitative polymerase chain reaction) expressions of the following fibrotic-related factors were determined: transforming growth factor-β1 (TGF- β1), collagen type I (COL1A1), collagen type III (COL3A1), and interleukin-17 (IL-17). The protein levels of TGF-β1, COL1A1, and COL3A1 were determined through immunohistochemistry and integrated optical densities.

Results:

Compared with all other groups, the untreated TS model had significantly thicker tracheal epithelium and lamina propria, and higher mRNA and protein levels of all targeted fibrotic factors. The mRNA and protein levels of the targeted fibrotic factors in all the drug-treated groups were lower than those of the untreated TS model, and differences were most significant in the erythromycin + budesonide group.

Conclusions:

Erythromycin combined with budesonide may reduce inflammation and modify fibrosis progression in TS after tracheal injury.

Airway Management via Laryngeal Mask in Laryngotracheal Resection

We present a case of impassable subglottic stenosis scheduled for tracheal resection and reconstruction managed by establishing a supraglottic airway. Despite careful preoperative evaluation, the stenosis was localized higher than anticipated, rendering conventional intubation impossible. Laryngeal mask bridging to cross-field ventilation was feasible and jet ventilation and cardiopulmonary bypass were available as emergency strategies. Surgery and emergence went uneventful. Perioperative considerations are discussed in this report.

Incidence Rate of Post-Intubation Tracheal Stenosis in Patients Admitted to Five Intensive Care Units in Iran

Background

Tracheal stenosis is one of the worst complications associated with endotracheal intubation and it is the most common reason for reconstructive airway surgeries. Due to various local risk factors, the incidence rate of tracheal stenosis may vary in different countries. In order to estimate the incidence rate of post-intubation tracheal stenosis (PITS) in patients admitted to an intensive care unit (ICU), a follow-up study was planned. As there was no similar methodological model in the literature, a feasibility step was also designed to examine the whole project and to enhance the follow-up rate.

Objectives

To estimate the PITS incidence rate in patients admitted to ICUs, as well as to evaluate the feasibility of the study.

Methods

This prospective cohort study was conducted in five hospitals in two provinces (Tehran and Arak) of Iran from November 2011 to March 2013. All patients admitted to ICUs who underwent more than 24 hours of endotracheal intubation were included. Upon their discharge from the ICUs, the patients received oral and written educational materials intended to ensure a more successful follow-up. The patients were asked to come back for follow-up three months after their extubation, or sooner in case of any symptoms developing. Those with dyspnea or stridor underwent a bronchoscopy. The asymptomatic patients were given a spirometry and then they underwent a bronchoscopy if the flow-volume loop suggested airway stenosis.

Results

Some seventy-three patients (70% men) were included in the study. Multiple trauma secondary to motor vehicle accidents (52%) was the most common cause of intubation. Follow-ups were completed in only 14 (19.2%, CI = 0.109 - 0.300) patients. One patient (7%, CI = 0.007 - 0.288) developed symptomatic tracheal stenosis that was confirmed by bronchoscopy. The barriers to a successful follow-up were assessed on three levels: ineffective oral education upon discharge, improper usage of educational materials, and difficulties to attending follow-up visits. There were also some important obstacles in terms of human, time, material, and cost resources, as well as data management.

Conclusions

To enhance the follow-up rate, three strategies were proposed: patient-focused strategies such as emphasizing patient education upon discharge and providing rewards; structural-focused strategies such as scheduling home visits and uploading questionnaires onto the research center’s website; and provider-focused strategies such as selecting coordinators with good communication skills. All necessary resources should also be re-arranged for a multicenter national study.

Intraoperative Tension Pneumothorax in a Patient With Remote Trauma and Previous Tracheostomy

Many trauma patients present with a combination of cranial and thoracic injury. Anesthesia for these patients carries the risk of intraoperative hemodynamic instability and respiratory complications during mechanical ventilation. Massive air leakage through a lacerated lung will result in inadequate ventilation and hypoxemia and, if left undiagnosed, may significantly compromise the hemodynamic function and create a life-threatening situation. Even though these complications are more characteristic for the early phase of trauma management, in some cases, such a scenario may develop even months after the initial trauma. We report a case of a 25-year-old patient with remote thoracic trauma, who developed an intraoperative tension pneumothorax and hemodynamic instability while undergoing an elective cranioplasty. The intraoperative patient assessment was made even more challenging by unexpected massive blood loss from the surgical site. Timely recognition and management of intraoperative pneumothorax along with adequate blood replacement stabilized the patient and helped avoid an unfavorable outcome. This case highlights the risks of intraoperative pneumothorax in trauma patients, which may develop even months after injury. A high index of suspicion and timely decompression can be life saving in this type of situation.

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.