Veno-venous extra-corporeal membrane oxygenation in complex tracheobronchial resection

Background

Elective extra-corporeal membrane oxygenation (ECMO) is rarely used in thoracic surgery, apart from lung transplantation. The purpose of this study was to summarize our institutional experience with the intraoperative use of veno-venous (VV) ECMO in selected cases of main airway surgery.

Methods

We retrospectively analyzed the data of 10 patients who underwent main airway surgery with the support of VV-ECMO between June 2013 and August 2022.

Results

Surgical procedures included: three carinal resection and reconstruction with complete preservation of the lung parenchyma, one right upper double-sleeve lobectomy and hemi-carinal resection, and one sleeve resection of the left main bronchus after previous right lower bilobectomy, for thoracic malignancies; four tracheal/carinal repair for extensive traumatic laceration; one extended tracheal resection due to post-tracheostomy stenosis in a patient who had previously undergone a left pneumonectomy. The median intraoperative VV-ECMO use was 162.5 minutes. In three cases with complex resection and reconstruction of the carina and in one case of extended post-tracheostomy stenosis and previous pneumonectomy, high-flow VV-ECMO allowed interruption of ventilation for almost 3 hours. In four patients, VV-ECMO was prolonged in the postoperative period to ensure early extubation. There were no perioperative deaths, no complications related to the use of ECMO and no intraoperative change in the planned type of ECMO. Significant complications occurred only in one patient who developed a small anastomotic dehiscence that led to stenosis and required placement of a Montgomery tube. At the median follow-up of 30 months, all 10 patients were still alive.

Conclusions

The use of intraoperative VV-ECMO allows safe and precise performance of main airway surgery with minimal postoperative morbidity in patients requiring complex resections and reconstructions and in cases that cannot be managed with conventional ventilation techniques.

Timing of Complications in Open Airway Reconstruction

OBJECTIVE

Tracheal resection (TR) and cricotracheal resection (CTR) are performed for patients with airway stenosis, tracheal tumor, and tracheoesophageal fistula. Post-operative complications include airway edema requiring reintubation, hematoma, anastomotic dehiscence, restenosis, and death. Although these complications and associated risk factors have been well described, the time where clinical suspicion should be highest post operatively has not been characterized.

METHODS

Patients who underwent TR or CTR at a single center between 2015 and 2022 were reviewed. Variables including demographics and comorbidities were recorded. Rate, nature, and time in days of post-operative complications were evaluated.

RESULTS

Sixty-nine cases were reviewed. Average patient age was 46.8 years old and 63.8% were male. The average follow-up period was 625 ± 724 days. 19 (27.5%) patients experienced one or more major complications including four (5.8%) who died. Eight (11.6%) patients required reintubation and 4 (5.8%) patients underwent revision tracheostomy. Most complications occurred within 8 days of surgery. Restenosis was noted an average of 42.6 days after surgery, with no new restenosis occurring after 3 months.

CONCLUSIONS

In this single-center study, most post-operative complications after TR or CTR, including hematoma and anastomotic dehiscence, occurred within 8 days post-operatively. Restenosis was noted approximately 1-3 months after surgery. This may inform clinical decision-making regarding patient monitoring and surveillance after open airway surgery.

LEVEL OF EVIDENCE

4 Laryngoscope, 2024.

Role of Loupes Magnification in Tracheal Resection and Anastomosis

Tracheal resection and anastomosis is characterized in the last years by significant innovations which are well codified and standardized. Although the mortality rate is markedly reduced, the operation is still not free from risk of complications such as recurrent laryngeal nerve injury, anastomosis dehiscence, granulation tissue formation and restenosis. Pearson FG, Cooper ID, Nelems JL (1975) Primary tracheal anastomosis after resection of the cricoide cartilage with preservation of the recurrent laryngeal nerves. J Thorac Cardiovasc Surg 70:806-16.

Supplementary Information

The online version contains supplementary material available at 10.1007/s12070-023-04115-3.

Post-Covid-19 Airway Stenosis: Tracheal Resection-Anastomosis Using The Tritube® Ventilation

We present a video of a tracheal resection and anastomosis performed on a patient affected by A-shaped tracheal stenosis. The condition was a consequence of a percutaneous tracheostomy following a Sars-Cov2 infection. Airways management during the surgery was obtained with the Tritube®, an innovative device with a very small lumen that combines stable lung parameters and good visualization of surgical field. Laryngoscope, 134:897-900, 2024.

How I Do It: Sternocleidomastoid Flap Augmentation of Tracheal Repair After Resection for Invasive Thyroid Cancer

Surgical treatment for thyroid carcinoma invading the trachea often involves circumferential tracheal resection and primary tracheal repair. This procedure involves a significant risk of anastomotic breakdown. We present a novel approach to cricotracheal repair using an SCM flap bolster designed to reduce the risk of anastomotic complications. Laryngoscope, 133:3228-3231, 2023.

Analysis of Complications in (Crico-) Tracheal Resection Anastomosis in Adults: A Multicenter Study

OBJECTIVES

The gold standard treatments for advanced laryngotracheal stenosis (LTS) are represented by partial crico-tracheal (PCTRA) or tracheal resection and anastomosis (TRA). These procedures are potentially burdened by high postoperative complication rates. We investigated the impact of the most common stenosis and patient-related characteristics on the onset of complications in a multicentric cohort.

METHODS

We retrospectively analyzed patients who underwent PCTRA or TRA for LTS of different etiologies in three referral centers. We tested the effectiveness of these procedures, the impact of complications on the outcomes, and identified factors causing postoperative complications.

RESULTS

A total of 267 patients were included in the study (130 females; mean age, 51.46 ± 17.64 years). The overall decannulation rate was 96.4%. Altogether, 102 (38.2%) patients presented at least one complication, whereas 12 (4.5%) had two or more. The only independent predictor of post-surgical complications was the presence of systemic comorbidities (p = 0.043). Patients experiencing complications needed additional surgery more frequently (70.1% vs. 29.9%, p < 0.001), and had a longer duration of hospitalization (20 ± 10.9 vs. 11.3 ± 4.1 days, p < 0.001). Six of 102 (5.9%) patients with complications had restenosis, although this event did not occur among patients without complications.

CONCLUSION

PCTRA and TRA have an excellent success rate even when performed for high-grade LTS. However, a significant percentage of patients may experience complications associated with a longer duration of hospitalization or the need for additional surgeries. The presence of medical comorbidities was independently related to an increased risk of complications.

LEVEL OF EVIDENCE

4 Laryngoscope, 133:2910-2919, 2023.

Operative technique: Tracheal resection and anastomosis in a revision surgery

Tracheal stenosis is an uncommon pathological condition in which the lumen of the trachea is reduced. Within its management an adequate preoperative workup is crucial to determine the most appropriate procedure for each patient. In this scenario tracheal resection and anastomosis is a viable approach, as a procedure in which part of the trachea is removed and then restored with a tension-free anastomosis. It is usually indicated for extensive and high-grade lesions or when previous endoscopic procedures had failed. The patient here presented had already undergone a balloon dilatation twice and a tracheal resection and referred to our clinic with a residual tracheal stenosis graded Myer-Cotton 3 involving three tracheal rings. We here illustrate step-by-step the surgical procedure and highlight a peculiar way to perform the anastomosis, especially in a revision surgery.

Tracheoesophageal Fistula as a Complication of Prolonged Ventilation in COVID-19: Description of Reconstruction and Review of the Literature

Infection with COVID-19 pneumonia may necessitate intubation and mechanical ventilation. Viral inflammation and pressure necrosis may lead to scarring, stenosis, and in severe cases, fistula formation. Nonmalignant tracheoesophageal fistulas (TEF) represent a surgical challenge and may necessitate locoregional tissue transfer and tracheal resection to prevent recurrence and maintain airway patency. We present a case of TEF in a 63-year-old female secondary to prolonged mechanical ventilation in the setting of COVID pneumonia, detailing the clinical findings and surgical repair. Primary closure of the esophageal defect with pectoralis major muscle flap onlay and tracheal resection, with median sternotomy for access, provided successful intervention, allowing for subsequent tracheostomy decannulation and return to a complete oral diet. This case offers further evidence of the increased risk of airway complications in COVID-19 infection and provides otolaryngologists with an example of a rare surgical approach useful in management.

Tracheal resection and primary reconstruction on venovenous extracorporeal membrane oxygenation

Cross-table ventilation during tracheal resection via posterolateral thoracotomy presents a technical challenge. With the ubiquity of venovenous extracorporeal membrane oxygenation (VV-ECMO), there is now a safe and feasible alternative for intraoperative respiratory support. Airway surgery on ECMO avoids prolonged periods of apnea or single lung ventilation, allowing patients with poor lung function to undergo surgery. Image-guided femoro-femoral cannulation using a low-dose heparin protocol minimizes the risk of bleeding while uncluttering the surgical field. By eliminating the need to constantly reposition the endotracheal tube, visualization is improved, and the rhythm of the case is maintained, which can shorten the anastomotic time. Here, we present a case where venovenous ECMO and total intravenous anesthesia were used to completely support a patient undergoing major tracheal surgery without the need for cross-table ventilation.

The role of local expression of hormone receptors in the genesis of idiopathic tracheal stenosis

Background

Tracheal stenosis in adults is usually the result of mechanical injuries either from direct trauma, tracheotomy or intubation. Idiopathic stenosis in the cricotracheal section is a rare condition and occurs almost exclusively in females. Therefore, an influence of the female sexual hormones estrogen and progesterone has been assumed previously.

Methods

Tracheal specimens of 27 patients who received tracheal resection for either idiopathic tracheal stenosis (ITS) (n=11) or posttraumatic tracheal stenosis (PTTS) (n=16) between 2008 and 2019 in our surgical department were included and retrospectively analyzed. Immunohistochemical staining of tracheal specimens concerning the hormone receptor status of progesterone and estrogen was performed.

Results

While post-tracheotomy stenosis occurred in males (n=6) as well as in females (n=10), none of the patients with idiopathic stenosis were males. All of the idiopathic stenosis (n=11; 100%) showed a strong expression of the estrogen receptors (ERs) in the fibroblasts and expression of progesterone receptors (PRs) in fibroblasts in 8 of 11 (72.7%). In the post-tracheotomy patients, only 3/16 (18.8%) showed slight staining of PRs and 6/16 (37.5%) of ERs. Of those, only one male patient presented with expression of ERs and PRs and another male patient presented with isolated PRs. Oral intake of hormone compounds was seen in 11/27 (40.7%) patients: 7/11 (63.6%) in the ITS group and 4/16 (25%) in the PTTS (noteworthy that the PTTS group included 6 male patients).

Conclusions

Although the number of patients is small, our results show that the expression of female sexual hormone receptors in the fibroblasts of the trachea is a persistent finding in ITS. Surgery provided good results with a favorable long-term outcome without recurrence of stenosis for ITS and PTTS. Further investigation with a special focus on hormones is needed to assist in the prevention of this rare disease.

Comparative Treatment Outcomes for Idiopathic Subglottic Stenosis: 5-Year Update

The North American Airway Collaborative (NoAAC) previously published a 3-year multi-institutional prospective cohort study showing variation in treatment effectiveness between 3 primary surgical techniques for idiopathic subglottic stenosis (iSGS). In this report, we update these findings to include 5 years of data evaluating treatment effectiveness. Patients in the NoAAC cohort were re-enrolled for 2 additional years and followed using the prespecified published protocol. Consistent with prior data, prospective observation of 487 iSGS patients for 5 years showed treatment effectiveness differed by modality. Cricotracheal resection maintained the lowest rate of recurrent operation (5%), followed by endoscopic resection with adjuvant medical therapy (30%) and endoscopic dilation (50%). These data support the initial observations and continue to provide value to providers and patients navigating longitudinal decision-making. Level of evidence: 2-prospective cohort study.

High Tracheal Resection With Intralaryngeal Extension as an Alternative to Cricotracheal Resection for Treatment of Subglottic Stenosis

OBJECTIVE

Some patients with subglottic stenosis (SGS) require open airway reconstruction, which traditionally involves resection of the anterior cricoid cartilage. As an alternative, we present a novel technique: cricoid-sparing high tracheal resection with excision of subglottic stenotic tissue from below. A novel set of posterior circumferential cricoid sutures is used to reline the exposed cricoid plate.

STUDY DESIGN

Retrospective chart review.

SETTING

Single tertiary care center.

METHODS

The surgical technique is described and illustrated. A chart review was performed for all patients who underwent surgery between January 1, 2016, and June 30, 2021.

RESULTS

Fourteen patients (100% female) underwent this airway resection and reconstruction surgery during the study time period. After a mean follow-up of 12 months, no patients required tracheostomy. Twelve of 14 patients (86%) had durable airways. Two patients (14%) have required repeated endoscopic procedures for recurrent stenosis and are considered treatment failures. None exhibited postoperative dysfunction to suggest posterior cricoarytenoid muscle injury. Thirteen patients (93%) had a postoperative normal voice or only transient dysphonia. One patient had permanent unilateral vocal fold paralysis.

CONCLUSION

Cricoid-sparing high tracheal resection is a safe and effective alternative to cricotracheal resection, especially for predominantly posterior SGS. The cricoid cartilage and cricothyroid muscles are left undisturbed, potentially decreasing the risk of postoperative dysphonia, namely lowered fundamental frequency. This is especially meaningful in the setting of a predominantly female patient population.

[Cicatricial tracheal stenosis in elderly and senile patients: immediate and long-term results of treatment]

OBJECTIVE

To present treatment outcomes in elderly and senile patients with cicatricial tracheal stenosis (CTS) and features of their perioperative management.

MATERIAL AND METHODS

The study included 46 elderly and senile patients with CTS. We analyzed their gender and age, body mass index, etiology, extent and degree of stenosis, comorbidity index and ASA grade, postoperative complications according to TMM grading system.

RESULTS

Age of patients varied from 61 to 95 years (mean 66.38±8.65). Post-intubation stenosis was detected in 7 (15.2%) patients, post-tracheostomy CTS - in 39 (84.8%) patients (2 (4.3%) ones with tracheoesophageal fistula and 18 (39.1%) ones with tracheomalacia). CTS length ranged from 8 to 65 mm. The causes of invasive mechanical ventilation were traumatic brain and spinal trauma in 6 cases, emergency surgery in 11 cases and therapeutic diseases in 29 cases. CTS of cervical trachea was found in 21 patients, subglottic larynx and cervical trachea - 8 patients, cervical and upper thoracic trachea - 12 patients, thoracic segment - 3 patients, multifocal lesions - 2 patients. The Charlson index ranged from 5 to 12 points. ASA grade II was observed in 8 (17.4%) patients, III - 28 (60.9%), IV - in other ones. Circular resection was performed in 5 patients, laryngotracheoplasty - in 37 patients. CTS repair and tracheoesophageal fistula closure with laryngotracheoplasty were carried out in 2 patients. Postoperative complications occurred in 18 (39.1%) patients, mortality was 2.17%. In 21.7% of cases, complications were associated with tracheal suture. Endoscopic procedures, cryosurgery and hyperbaric oxygenation were used for correction. Good and satisfactory treatment outcomes were achieved in 86.5% of patients.

CONCLUSION

Surgical treatment of CTS in elderly and senile patients requires participation of interdisciplinary team with special experience. Laryngotracheoplasty is safe and effective in these patients, and indications for circular resection are still limited.

[Treatment of cicatricial tracheal stenosis and tracheoesophageal fistula in patients with COVID-19 pneumonia]

OBJECTIVE

To describe treatment of cicatricial tracheal stenosis and tracheoesophageal fistula in patients with COVID-19 pneumonia.

MATERIAL AND METHODS

There were 91 patients with cicatricial tracheal stenosis for the period from August 2020 to April 2022 (21 months). Of these, 32 (35.2%) patients had cicatricial tracheal stenosis, tracheoesophageal fistula and previous coronavirus infection with severe acute respiratory syndrome. Incidence of iatrogenic tracheal injury following ventilation for viral pneumonia in the pandemic increased by 5 times compared to pneumonia of other genesis. Majority of patients had pneumonia CT grade 4 (12 patients) and grade 3 (8 patients). Other ones had pulmonary parenchyma lesion grade 2-3 or mixed viral-bacterial pneumonia. Isolated tracheoesophageal fistula without severe cicatricial stenosis of trachea or esophagus was diagnosed in 4 patients. In other 2 patients, tracheal stenosis was combined with tracheoesophageal fistula. Eight (25%) patients had tracheostomy at the first admission. This rate was almost half that of patients treated for cicatricial tracheal stenosis in pre-pandemic period.

RESULTS

Respiratory distress syndrome occurred in 1-7 months after discharge from COVID hospital. All patients underwent surgery. In 7 patients, we preferred palliative treatment with dilation and stenting until complete rehabilitation. In 5 patients, stent was removed after 6-9 months and these ones underwent surgery. There were 3 tracheal resections with anastomosis, and 2 patients underwent tracheoplasty. Resection was performed in 3 patients due to impossible stenting. Postoperative course in these patients was standard and did not differ from that in patients without viral pneumonia. In case of tracheoesophageal fistula, palliative interventions rarely allowed isolation of trachea. Four patients underwent surgery through cervical approach. There were difficult surgeries in 2 patients with tracheoesophageal fistula and cicatricial tracheal stenosis. One of them underwent separation of fistula and tracheal resection via cervical approach at primary admission. In another patient with thoracic fistula, we initially attempted to insert occluder. However, open surgery was required later due to dislocation of device.

CONCLUSION

Absolute number of patients with tracheal stenosis, tracheoesophageal fistula and previous COVID-19 has increased by several times compared to pre-pandemic period. This is due to greater number of patients requiring ventilation with risk of tracheal injury, non-compliance with preventive protocol for tracheal injury including anti-ischemic measures during mechanical ventilation. The last fact was exacerbated by involvement of allied physicians with insufficient experience of safe ventilation in the «red zone», immunodeficiency in these patients aggravating purulent-inflammatory process in tracheal wall. The number of patients with tracheostomy was 2 times less that was associated with peculiarity of mechanical ventilation in SARS-CoV-2. Indeed, tracheostomy was a poor prognostic sign and physicians tried to avoid this procedure. Incidence of tracheoesophageal fistula in these patients increased by 2 times compared to pre-pandemic period. In subacute period of COVID-associated pneumonia, palliative measures for cicatricial tracheal stenosis and tracheoesophageal fistula should be preferred. Radical treatment should be performed after 3-6 months. Absolute indication for circular tracheal resection with anastomosis is impossible tracheal stenting and ensuring safe breathing by endoscopic methods, as well as combination of cicatricial tracheal stenosis with tracheoesophageal fistula and resistant aspiration syndrome. Incidence of postoperative complications in patients with cicatricial tracheal stenosis and previous mechanical ventilation for COVID-19 pneumonia and patients in pre-pandemic period is similar.

A New Approach in Airway Management for Tracheal Resection and Anastomosis: A Single-Center Prospective Study

OBJECTIVES

The evaluation of the use of laryngeal mask airways (LMA) as an alternative form of airway management for surgical tracheal reconstruction.

DESIGN

A prospective case series.

SETTING

At a single German university hospital.

PARTICIPANTS

Ten patients.

INTERVENTIONS

The use of LMA for airway management in surgical reconstruction of the trachea.

MEASUREMENTS AND MAIN RESULTS

Ten patients with tracheal stenosis of 50% to 90% were enrolled prospectively during the study period. The airway management consisted of the insertion of an LMA. During resection and reconstruction, high-frequency jet ventilation was used. Several arterial blood gas analyses (ABG) were performed before, during, and after the tracheal resection and reconstruction. All values were presented as median and interquartile ranges or as absolute and relative values, and no emergency change to cross-field intubation was necessary. The lowest PaO₂ was 93 mmHg in 1 patient after 20 minutes of jet ventilation, whereas PaO₂ increased after the induction phase and remained stable in 9 patients. There were no intraoperative complications related to anesthetic management apart from transient hypercarbia during and after jet ventilation. Preoperative and postoperative ABG were comparable. One patient required immediate postoperative ventilatory support. Two patients developed postoperative pneumonia, leading to their admission to the intensive care unit. One patient was operated with a palliative approach due to massive dyspnea and died in the next postoperative course.

CONCLUSIONS

The use of LMA is an alternative option in airway management for tracheal reconstruction, even in patients with significant tracheal stenosis. Potential advantages compared to tracheal intubation are unimpaired access to the operative field and the lack of stress on the fresh anastomosis.

The critical period for development of secondary restenosis following post-intubation tracheal stenosis surgery

BACKGROUND

Determining a predictable duration to restenosis very essential for reducing mortality and morbidity for tracheal stenosis surgery.

OBJECTIVES

The aim of this study was to determine the critical periods for secondary restenosis risk for operated patients with post-intubation tracheal stenosis (PITS) during the initial healing period.

METHODS

A total of 61 patients with a diagnosis of surgically treated PITS were included in the study. Treatment groups were carbon dioxide (CO₂) laser and tracheal resection with primary anastomosis (TRPA). Duration to restenosis was compared with Kaplan-Meier curves between study groups.

RESULTS

Restenosis developed in 11 (18.0%) patients and was diagnosed after a mean of 39.3 ± 38.5 (range, 22 to 155) days. Gender or Cotton-Myer grade of the PITS was not found to be risk factors for the development of stenosis. Restenosis rate was 33.3% in CO₂ laser group and 10% in the TRPA group (p = .036). Duration to restenosis was detected at a median of 28 days in patients treated with CO₂ laser, and a median of 30 days in patients treated with TRPA (p = .024).

CONCLUSIONS

The most critical period for the development of restenosis after PITS treatment is the third and fourth weeks, especially in patients treated with CO₂ laser.

Tracheal Stenosis After Prolonged Intubation Due to COVID-19

Objectives

The authors aimed to evaluate the characteristics and management outcomes of patients who developed tracheal stenosis after invasive mechanical ventilation (IMV) due to COVID-19.

Design, Setting, and Participants

The data of 7 patients with tracheal stenosis and 201 patients without tracheal stenosis after IMV due to COVID-19 between March 2020 and October 2021 were retrospectively analyzed.

Interventions

Flexible bronchoscopy was performed for the diagnosis of tracheal stenosis and the evaluation of the treatment's effectiveness, and rigid bronchoscopy was applied for the dilatation of tracheal stenosis.

Measurements and Main Results

In the follow-up period, tracheal stenosis was observed in 7 of 208 patients (2 women, 5 men; 3.3%). The patients were divided into 2 groups as patients with tracheal stenosis (n = 7) and patients without tracheal stenosis (n = 201). There were no statistically significant differences between the 2 groups in terms of age, sex, body mass index, and comorbidities (p > 0.05). The mean duration of IMV of the patients with tracheal stenosis was longer than patients without tracheal stenosis (27.9 ± 13 v 11.2 ± 9 days, p < 0.0001, respectively). Three (43%) of the stenoses were web-like and 4 (57%) of them were complex-type stenosis. The mean length of the stenoses was 1.81 ± 0.82 cm. Three of the patients were treated successfully with bronchoscopic dilatation, and 4 of them were treated with tracheal resection.

Conclusions

Tracheal stenosis developed in 7 of 208 (3.3%) patients with COVID-19 who were treated with IMV. The most important characteristic of patients with tracheal stenosis was prolonged IMV support.

A novel technique for management of stenosis of the postlaryngectomy stoma with preservation of a functional tracheoesophageal puncture following tracheal resection

Tracheostomal stenosis following total laryngectomy presents a serious concern for surgeons and patients. Although various techniques correct tracheostomal stenosis, none address an existing tracheoesophageal puncture (TEP). We present an approach to repair tracheostomal stenosis, requiring tracheal resection, and preserve the TEP in a functional position needed for speech rehabilitation. A 62-year-old male with squamous carcinoma of the right true vocal fold underwent a salvage total laryngectomy with placement of a tracheoesophageal prosthesis. Seven years later, he developed tracheal narrowing. A tracheal resection and tracheoplasty were performed to manage the stenosis while maintaining the tracheoesophageal puncture. Six months postoperatively, the patient was well, with no stomal narrowing or trend toward collapse and uneventful healing. He achieved fluent voice easily with stomal occlusion. We present a novel surgical technique to correct for tracheostomal stenosis following total laryngectomy. Our technique allows for TEP preservation to facilitate speech rehabilitation postoperatively.

[Treatment of post-intensive care tracheal stenosis after previous covid-19 pneumonia]

OBJECTIVE

To analyze postoperative outcomes and perioperative management of patients with post-intensive care tracheal stenosis and previous COVID-19 pneumonia.

MATERIAL AND METHODS

There were 8 patients with post-intensive care tracheal stenosis and previous COVID-19 pneumonia aged 34-61 years between January 2021 and April 2021. Lung damage CT-3 was observed in 2 (25%) patients, CT-4 - in 5 (62.5%) patients. In one case, COVID-19 pneumonia with lung damage CT-2 joined to acute cerebrovascular accident. Post-tracheostomy stenosis was detected in 7 (87.5%) cases, post-intubation stenosis - in 1 patient. Duration of invasive mechanical ventilation ranged from 5 to 130 days. In 75% of cases, tracheal stenosis was localized in the larynx and cervical trachea. Two patients admitted with tracheostomy. In one case, an extended tracheal stenosis was combined with atresia of infraglottic part of the larynx. One patient had tracheal stenosis combined with tracheoesophageal fistula (TEF). Length of tracheal stenosis was 15-45 mm. Tracheomalacia was observed in 4 (50%) patients. All patients had severe concomitant diseases.

RESULTS

To restore airway patency, we used circular tracheal resection with anastomosis, laryngotracheoplasty and endoscopic methods. Tracheal resection combined with TEF required circular tracheal resection with disconnection of fistula. Adequate breathing through the natural airways was restored in all patients. There was no postoperative mortality. Three patients with baseline tracheal stenosis had favorable postoperative outcomes after circular tracheal resection. Four patients are at the final stage of treatment after laryngotracheoplasty and tracheal stenting.

CONCLUSION

Patients after invasive mechanical ventilation for COVID-19 pneumonia are at high risk of cicatricial tracheal stenosis and require follow-up. Circular tracheal resection ensures early rehabilitation and favorable functional results. Laryngotracheoplasty is preferred if circular tracheal resection is impossible. This procedure ensures adequate debridement of tracheobronchial tree and respiratory support. Endoscopic measures are an alternative for open surgery, especially for intrathoracic tracheal stenosis and intractable tracheobronchitis.

A retrospective study of 48 patients

OBJECTIVE

The objective was to prove efficiency of tracheal resection in the cohort of patients of our clinic and to introduce our own modification of T-cannula as a surgical alternative if tracheal resection is contraindicated.

BACKGROUND

Benign tracheal stenosis, the most often represented by post tracheostomy (PTTS) and post intubation (PITS) stenosis, is a rare, but serious and potentially life-threatening medical condition. We present our experience with the management of the patients, who were referred with a benign tracheal stenosis.

METHODS

In the retrospective study, patient's outcome was evaluated after tracheal resection or treatment with T-cannula from all the patients presented with a benign tracheal stenosis from January 2015 to January 2021.

RESULTS

The cohort consists of forty-eight patients. Thirty-one (64,6 %) patients underwent a tracheal resection and seventeen (35,4 %) were treated with tracheostomy and T-tube insertion. In the series of patients after tracheal resection, we observed no mortality, complications occurred in ten (32,2 %) patients. They were spread proportionally; anastomotic complications were noticed in 5 (16,1 %) patients, as well as non-anastomotic complications.

CONCLUSION

Tracheal resection is a safe and effective procedure with good results. T- tube insertion presents a surgical alternative if bronchoscopy is unavailable or failed (Tab. 4, Fig. 2, Ref. 20).

[Surgery of primary tracheal tumors]

OBJECTIVE

To determine the main forms of primary tracheal cancer (PTC), to specify the indications for various surgeries in these patients depending on extent and localization of lesion.

MATERIAL AND METHODS

There were 263 PTC patients. Benign tumors were diagnosed in 68 (25.9%) patients, malignancies - in 195 (74.1%) cases. Tracheal cancer includes 3 basic morphological variants - adenocystic cancer (49.7%), carcinoid (18.7%) and squamous cell carcinoma (19.0%). Other forms of malignancies were much less common. We applied endoscopic intraluminal and open surgeries. In malignant PTC, open surgeries were performed in 165 (84.6%) out of 195 patients. Baseline palliative endoscopic treatment was performed in 30 patients. They underwent airway recanalization (with subsequent tracheal stenting in 19 patients). Endoscopic resection was preferred for benign tumors.

RESULTS

Twenty (12.1%) patients died after open surgery, and 1 (3.3%) patient died after endoscopic procedure. Most lethal outcomes occurred in early years of development of tracheal surgery. The causes of mortality were tracheal anastomotic failure in 12 patients, pneumonia in 6 patients, and arterial bleeding in 2 patients. Severe postoperative period was observed in all 3 patients after tracheal replacement with a silicone prosthesis. Long-term treatment outcomes depended on morphological structure of PTC. Favorable results were observed in patients with neuroendocrine tumor (carcinoid), worse outcomes in adenocystic cancer and unfavorable results in squamous cell carcinoma (p<0.0013). Five-year survival rates were 75%, 65.6%, and 13.3%; 10-year survival rates were 75%, 56.2%, and 13.3%, respectively. These outcomes after combined treatment of primary tracheal cancer were significantly better compared to lung cancer (p<0.05 when compared to global data).

CONCLUSION

Treatment of primary tracheal cancer should be based on classical principles of modern oncology (combined therapy, tumor resection with lymphadenectomy). Open and endoscopic interventions are justified. PTC is characterized by more favorable outcomes compared to lung cancer. It is difficult to analyze long-term results in tracheal cancer depending on various features of tumor process due to small number of observations. Accurate conclusions require multiple-center studies, preferably with international participation, which can convincingly prove certain concept.

[A non-standard approach in the treatment of post-traumatic multifocal cicatricial tracheal stenosis with atresia of subglottic larynx, involvement of vocal cords and 33-year cannulation]

The report presents a case of non-standard two-stage treatment of post-traumatic multifocal cicatricial tracheal stenosis with atresia of subglottic larynx, involvement of vocal cords, and 33-year cannulation. At the first stage, bougienage through a tracheostomy, endoscopic argon plasma exposure, circular tracheoglottic resection with tracheostomy and ³/₄ circle anastomosis, formation of a laryngotracheostomy with endoprosthetics were applied simultaneously. The second step was to eliminate the extensive fenestrated tracheo-laryngeal defect using titanium nickelide reinforcing implants. The individual algorithm made it possible to successfully eliminate complex tracheo-laryngeal stenosis with long-term cannulation and demonstrate excellent long-term treatment results.

[Treatment of laryngotracheal and tracheal cicatricial stenosis: 10-year experience]

OBJECTIVE

To describe 10-year experience of treating the cicatricial tracheal stenosis (CTS) in a regional multi-field hospital.

MATERIAL AND METHODS

There were 120 CTS patients aged 13-75 years. In 8 (6.7%) patients, CTS was combined with tracheoesophageal fistula (TPF). Post-intubation stenosis was diagnosed in 16 (13.3%) cases, post-tracheostomy - in 102 (85%) ones, post-traumatic - in 2 (1.7%) patients. CTS length ranged from 1.2 to 8 cm. Fifty (41.7%) patients had cervical CTS, 40 (33.3%) patients - cervico-thoracic tracheal stenosis, 11 (9.2%) patients - tracheal stenosis at the thoracic level. Nineteen (15.8%) patients had multifocal stenoses. We used endoscopic techniques, circular tracheal resection (CTR) and laryngotracheal reconstruction.

RESULTS

Postoperative mortality rate was 0.83%. CTR was performed in 33 patients, laryngotracheal reconstruction - 77, endoscopic stenting - 6 patients. In 4 cases, local CTS was eliminated by bougienage and argon plasma exposure. CTS was successfully disconnected with TEF using CRT in 3 cases, laryngotracheoplasty and stenting - in 5 cases. The fenestrated tracheal defect was closed by a three-layer autologous flap in 59 patients. Of these, autologous flap was reinforced with porous nickel-titanium implants in 17 patients. Postoperative complications after CRT occurred in 6 (16.7%) patients (anastomotic leakage - 2, anastomositis - 1, restenosis - 2). No patients died. Postoperative complications after laryngotracheal reconstruction were observed in 18 (23.4%) patients including 5 ones with restenosis who underwent CTR with a favorable outcome.

CONCLUSION

CTS treatment requires a multidisciplinary approach. Each surgery has certain indications and place in treatment algorithm. CTR is highly effective, but may be accompanied by complications associated with tracheal anastomosis. Decrease of postoperative morbidity will improve immediate and long-term results of CTS treatment. The chosen treatment algorithm ensured good and satisfactory results in 98% of patients.

Tracheal and Cricotracheal Resection With End-to-End Anastomosis for Locally Advanced Thyroid Cancer: A Systematic Review of the Literature on 656 Patients

Airway involvement by advanced thyroid carcinoma (TC) constitutes a negative prognosticator, besides being a critical clinical issue since it represents one of the most frequent causes of death in locally advanced disease. It is generally agreed that, for appropriate laryngo-tracheal patterns of invasion, (crico-)tracheal resection and primary anastomosis [(C)TRA] is the preferred surgical technique in this clinical scenario. However, the results of long-term outcomes of (C)TRA are scarce in the literature, due to the rarity of such cases. The relative paucity of data prompts careful review of the available relevant series in order to critically evaluate this surgical technique from the oncologic and functional points of view. A systematic review was conducted according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses statement on the PubMed, Scopus, and Web of Science databases. English-language surgical series published between January 1985 and August 2021, reporting data on ≥5 patients treated for TC infiltrating the airway by (C)TRA were included. Oncologic outcomes, mortality, complications, and tracheotomy-dependency rates were assessed. Pooled proportion estimates were elaborated for each end-point. Thirty-seven studies were included, encompassing a total of 656 patients. Pooled risk of perioperative mortality was 2.0%. Surgical complications were reported in 27.0% of patients, with uni- or bilateral recurrent laryngeal nerve palsy being the most common. Permanent tracheotomy was required in 4.0% of patients. Oncologic outcomes varied among different series with 5- and 10-year overall survival rates ranging from 61% to 100% and 42.1% to 78.1%, respectively. Five- and 10-year disease specific survival rates ranged from 75.8% to 90% and 54.5% to 62.9%, respectively. Therefore, locally advanced TC with airway invasion treated with (C)TRA provides acceptable oncologic outcomes associated with a low permanent tracheotomy rate. The reported incidence of complications, however, indicates the need for judicious patient selection, meticulous surgical technique, and careful postoperative management.

Extracorporeal Membrane Oxygenation Use in Thoracic Surgery

This narrative review is focused on the application of extracorporeal membrane oxygenation (ECMO) in thoracic surgery, exclusive of lung transplantation. Although the use of ECMO in this indication is still rare, it allows surgery to be performed in patients where conventional ventilation is not feasible-especially in single lung patients, sleeve lobectomy or pneumonectomy and tracheal or carinal reconstructions. Comparisons with other techniques, various ECMO configurations, the management of anticoagulation, anesthesia, hypoxemia during surgery and the use of ECMO in case of postoperative respiratory failure are reviewed and supported by two cases of perioperative ECMO use, and an overview of published case series.

Expert Technique: Pediatric Tracheal Surgery

Substantial improvements in techniques of tracheal surgery for children have occurred in the past 20 years. Precise preoperative imaging with computed tomography clearly defines the anatomy for surgical planning and is assisted by on-the-table needle localization. The use of cardiopulmonary bypass greatly facilitates creation of an airtight, widely patent trachea. The use of Ciprodex as a postoperative nebulizer has significantly decreased granulation tissue along the suture line. Most important has been the adoption of slide tracheoplasty as the procedure of choice.

Comparison of tracheal resection outcomes at a university hospital vs county hospital setting

OBJECTIVES

To evaluate the role of hospital setting on outcomes in open airway surgery by comparing patients who underwent surgery (cricotracheal resection [CTR] or tracheal resection [TR]) at a publicly funded county hospital vs a private university hospital.

METHODS

Retrospective chart review of patients undergoing CTR or TR at two institutions; a private university hospital and a publicly funded county hospital from September 2014 to September 2019. Length of intensive care unit (ICU) stay, total time to discharge, minor and major complications were the primary endpoints. Significance was defined as a P-value less than .05.

RESULTS

There were a total of 43 patients (17 county, 26 university) who had CTR or TR during the study period. Length of stay outcomes was reported as mean length of stay ± SD. There was a significant difference in ICU stay at the county hospital (7.17 (±5.36 days) compared to the university hospital (2.52 ± 1.85 days, P < .003) and a nearly significant total length of stay difference at the county hospital (12.4 ± 9.06 days) compared to the university hospital (7.84 ± 4 days, P < .072) There was overall a low incidence of complications but slightly more in the county compared to the university population.

CONCLUSION

Patients who underwent open airway surgery at the county hospital were more likely to have a longer ICU stay and slight increase in complications despite having a lower ASA (American Society of Anesthesiologists) classification and younger age. These outcomes are multifactorial and may be related to poorer access to primary care preoperatively leading to delay in diagnosis and treatment, poorly controlled or undiagnosed medical comorbidities, and differences in hospital resources.

LEVEL OF EVIDENCE

IV.

[Assessment of tracheal elasticity and tracheal anastomosis tension in cicatricial stenosis]

OBJECTIVE

To assess the tracheal elasticity and tracheal anastomosis tension for prevention of anastomosis-related complications and estimation of the maximum length of resection.

MATERIAL AND METHODS

At the first stage, 20 patients with cicatricial tracheal stenosis underwent tracheoscopy in usual position, under maximum flexion and extension of the head for the period from September 2017 to December 2019. We measured the total length of trachea and length of stenotic segment. Tracheal extensibility was assessed considering the difference in measurements. At the second stage, anastomosis tension was intraoperatively measured using a dynamometer in normal head position, as well as at maximum flexion in 22 patients who underwent tracheal resection. Unlike multiple other studies, we studied tissue tension intraoperatively.

RESULTS

Mean length of trachea was 12.8 cm, extensibility - 1.3 cm. Tracheal elasticity was greater in patients with a longer trachea and in patients under 40 years old. Mean length of resection was 3.9 cm (30% of mean length of trachea), anastomosis tension - 2.7 H or 270 g. Head flexion was followed by tension decrease by 0.7 H (26.9%), i.e. 70 g. This approach is less effective in case of resection of more than 30% of trachea length in a particular patient.

CONCLUSION

Further experience in measurement of tracheal extensibility and anastomosis tension will make it possible to establish clinical significance of these indicators for prevention of complications.

Airway management by i-gel for open tracheal resection and reconstruction via combined cervicotomy and sternotomy surgical approach: A case report

Surgical resection and tracheal reconstruction are the most effective treatment options for airway stenosis. Tracheal surgery is challenging and requires a multidisciplinary approach and a highly specialized team of anesthesiologists and thoracic surgeons that are "sharing the airways". Several airway management tools, different devices, and various approaches can be required to ensure ventilation and gas exchange. We describe the case of a patient affected by tight tracheal stenosis, submitted to tracheal resection and reconstruction via combined cervicotomy and sternotomy surgical approach. Airway management was successfully performed by i-gel^® (Intersurgical, UK) supraglottic device.

Surgical management of tracheal chondrosarcoma

Background: Tracheal chondrosarcoma is an extremely rare, slow-growing, malignant tumour. This study aims to analyze the cases of tracheal chondrosarcoma published in the literature and our case report, in order to better define tracheal chondrosarcoma management.Methods: A systematic review of the English literature was carried out for fully described tracheal chondrosarcoma cases. Additionally, we reported a new case of a 58-year-old man undergoing tracheal resection and reconstruction for tracheal chondrosarcoma.Results: To date, 30 cases were published. This tumour predominantly involved male patients (93%; median age: 65 years), generally conditioning dyspnoea and cough. Most of the patients underwent tracheal resection with end-to-end anastomosis, without recurrence (median follow-up: 2 years). Tumours endoscopically treated recurred in half cases.Conclusion: Tracheal resection is the treatment of choice for chondrosarcoma, with an excellent prognosis. Endoscopic treatment and/or radiotherapy should be indicated for patients unfit for surgery.

From the clavicle to the windpipe: Tracheal window resections reconstructed with calcifying periosteum in thyroid cancer

OBJECTIVES

We aimed to evaluate the outcomes of tracheal window resection and reconstruction using a vascularized periosteal flap (intended for calcification) harvested from the medial clavicle. This is one of several surgical techniques for tracheal resection and reconstruction used for patients with thyroid carcinoma invading the trachea. Importantly, in partial tracheal resection postoperative dynamic airway collapse must be prevented. Reconstruction of the tracheal defect with a vascularized periosteal flap is one method of achieving a stable airway.

METHODS

Twelve patients with locally advanced thyroid carcinoma who underwent tracheal resection and reconstruction at Oslo University Hospital from 2004 to 2017 were studied retrospectively. The primary outcome was a stable airway not requiring airway stenting. The secondary outcomes were the time to decannulation, morbidity, and survival.

RESULTS

Eleven of 12 patients did not require airway stenting postoperatively after a median of 111 days. Seven patients developed postoperative complications. The median observation time was 74.8 months (range 10.5-153.5) for all patients. The median disease-free survival was 40 months (range 0-147). By February 1, 2020, seven patients were alive, of whom five showed no evidence of disease.

CONCLUSIONS

Tracheal reconstruction with a vascularized periosteal flap yielded good results in terms of establishing a stable airway. This procedure is a viable reconstructive option that allows for decannulation by preventing airway collapse, thereby potentially mitigating the need for end-to-end (ETE) anastomosis or sleeve resections. For selected patients, this procedure may prevent local fatal complications from thyroid cancer invading the trachea.

LEVEL OF EVIDENCE

Level 4.

[Contamination of surgical wound during tracheal resection depending on the mode of mechanical ventilation]

OBJECTIVE

To analyze contamination of surgical wound during tracheal resection depending on the mode of mechanical ventilation.

MATERIAL AND METHODS

There were 976 patients. Circular tracheal resection was made in 396 of these patients.

RESULTS

Overall postoperative morbidity was 15.7%, mortality - 0.8%. Bacteriological examination of surgical wound was performed before tracheotomy and after formation of anastomosis depending on the method of mechanical ventilation. Surgical field was sterile before tracheotomy in all cases, contamination was confirmed after tracheotomy in all patients. Minimal contamination was observed in case of apneic oxygenation (100 times less than volumetric mechanical ventilation or high frequency mechanical ventilation). In all cases, several species of pathogenic microorganisms were identified. The number of species was also minimal in case of hypnotic mechanical ventilation.

CONCLUSION

Contamination does not directly affect the development of local purulent-inflammatory process. However, this factor should not be ignored and compliance with all preventive measures is required.

[Circular resection of the thoracic trachea for MALT lymphoma in an 81-year-old patient]

A rare clinical observation of primary tracheal MALT lymphoma is reported and difficulties of differential diagnosis are discussed. Tracheal neoplasms are rare tumors and characterized by delayed diagnosis after clinical manifestation (tracheal stenosis and associated complications). These tumors often occur an advanced age patients that complicates examination and surgical treatment. High risk is determined by type of surgery, possible postoperative complications and senile age.

Stair-step tracheal repair: Surgical technique

Typical surgical treatment for invasive thyroid carcinoma at the level of the cricoid substantially reduces surrounding cartilaginous support and risks damage to the recurrent laryngeal nerve (RLN). We present a novel tracheal reconstructive technique that minimizes this injury risk. A 72-year-old man with recurrent invasive thyroid carcinoma underwent cricotracheal resection and reconstruction using a stair-step approach. Diseased cartilage was removed by a left hemitracheal and hemicricoid resection. A portion of normal trachea was also resected on the contralateral right side, removing the third and fourth hemitracheal rings, to close the defect with a sliding tracheoplasty and avoid dissection near the right cricothyroid joint on the side of the functioning RLN. The trachea was elevated superiorly and reanastomosed to the cut margin of the cricoid. This novel stair-step approach to tracheal reconstruction offers reduced risk of injury to the contralateral RLN while still establishing a patent airway.

Tracheolaryngeal Squamous Cell Carcinoma with Extensive Mucosal Spread Without Metastasis in a Female

Tracheal tumors remain one of the most interesting and challenging respiratory tumors. Usually, with the more invasive histologic subtypes, cancer has already invaded surrounding structures at the time of diagnosis. We present an unusual case of primary tracheal squamous cell carcinoma with an extensive mucosal spread at the time of diagnosis without any invasion of surrounding organs or distant metastasis. We discuss the unique features and our treatment approach to this unusual presentation. We also discuss the various epidemiologic, diagnostic and treatment aspects of upper airways tumors of the hypopharynx, larynx, and trachea that can help patients achieve more favorable outcomes.

Tracheal resection for tracheal stenosis

Anatomically, patients with refractory tracheal stenosis benefit from tracheal resection, depending on the medical comorbidities or challenging tracheal anatomy, which is often the reason for denial of this option in these patients. We evaluated 15 patients undergoing tracheal resection at our institution from May 2016 through December 2017. Eleven patients had a history of previous tracheostomy, six in place at the time of resection. One had idiopathic stenosis with no known comorbidities. Major comorbidities included chronic obstructive pulmonary disease, non-insulin-dependent diabetes mellitus, hypertension, and cardiovascular disease. One had a left ventricular assist device, and one was a lung transplant recipient. All had primary resection through the cervical approach with a median length of 3.5 cm. Fourteen patients were eventually decannulated. One patient had re-resection 1 year later for recurrent stenosis. Twelve were alive at a median follow-up of 15 months with patent airways. In conclusion, tracheal stenosis patients have significant comorbidities that increase the risks after resection. However, these patients should still be considered for surgery for an improved quality of life and eventual resolution of severe stenosis.

[Surgical treatment of extensive posttracheostomy tracheal stenosis using a new technique]

We report one-stage radical surgical treatment of a 54-year-old patient with extensive cicatricial posttracheostomy tracheal stenosis complicated by tracheomalacia of anterior tracheal wall and previous numerous unsuccessful endoscopic attempts of tracheal recanalization. A new method of prevention of tracheal anastomosis failure was applied.

[Tracheal resection after prolonged stenting in surgery for cicatricial stenosis]

OBJECTIVE

To analyze early and delayed results of various variants of circular tracheal resection (CTR) with anastomosis, to determine the safest approach, dates and conditions of correction, features of postoperative period in patients after previous tracheal surgery.

MATERIAL AND METHODS

There were 831 patients with cicatricial tracheal stenosis. CTR was made in 330 (39.7%) patients. Most patients had previous prolonged ICU-stay. The patients were divided into 4 groups. Group 1 consisted of 61 (18.5%) patients after previous prolonged tracheal stenting. Group 2 included 45 (13.6%) patients who underwent circular tracheal resection with a functioning tracheostomy. Tracheostomy tube served as a stent in these patients. Group 3 enrolled 32 (9.7%) patients with previous staged reconstructive plastic surgeries on cranial segment of the respiratory tract. Tracheostomy or stent were absent in 192 (58.2%) patients who underwent circular tracheal resection at the first hospitalization. These patients were enrolled into the fourth (control) group. Favorable outcomes (without complications and mortality) were achieved in 85.5% (n=282) of patients. Postoperative complications occurred in 48 (14.5%) patients. Mortality rate was 0.6% (n=2). The greatest number of complications including anastomositis and restenosis was noted in patients after CTR and previous tracheoplasty with T-tube (n=8, 25%). The most common complication in patients after tracheal resection and previous stenting was anastomositis (14.7%). Long-term results depended on postoperative complications and methods of their correction. Recurrent stenosis occurred in 5 (1.5%) patients within the period of 3 months - 8 years. CTR after previous tracheoplasty with T-tube was carried out in 4 of these patients.

CONCLUSION

Tracheal resection after preliminary stenting or tracheostomy is quite safe and technically feasible. Stenting allows postponing radical surgery for correction of concomitant diseases and closure of tracheostomy as a focus of infection within the surgical approach and further tracheal anastomosis. Tracheal resection with simultaneous closure of tracheostomy results a higher rate of postoperative complications compared with preliminary stenting.

Corrosive injury of the trachea in children

The secondary injury may present weeks to months after the initial insult and repeat bronchoscopy, and long-term follow-up is required for the respiratory complications of CSI.Ingestion of caustic fluid may cause severe tracheal stenosis. Repeated airway dilatation may be a lifesaving intervention until such point that surgery can be performed.

Postintubation tracheal stenosis: Surgical management

Postintubation tracheal stenosis (PITS) is a known complication of endotracheal intubation or tracheostomy. It is the most common indication for tracheal resection/reconstructive surgery. Despite technological improvement and skilled patient care in the ICU, PITS still constitutes an important group of iatrogenic sequela after intubation. With increasing number of patients requiring ICU admission and mechanical ventilation in Nigeria, it is important that this complication is prevented from occurring. The care of such patients often is technically challenging. The successful management by resection and end-to-end anastomosis of a 37-year-old man presenting with 2 cm length of severe tracheal stenosis of 4 mm luminal diameter following prolonged endotracheal intubation and who had had repeated bronchial dilatation is presented.

[Circular tracheal resection for acquired tracheal stenosis: evaluation of early and long-term outcomes]

AIM

To present single-center experience and results of surgical treatment of acquired tracheal stenosis.

MATERIAL AND METHODS

There were 99 patients with acquired tracheal stenosis for the period from January 2008 to December 2017. Median age was 39 (28; 55) years (range 19-79 years), male/female ratio - 64/35. There were 59 patients with tracheostomy-related stenosis, 31 - post-intubation injury, 6 - posttraumatic stenosis, malignant and idiopathic stenosis was observed in 2 and 1 patients, respectively. Single-stage circular tracheal resection or staged surgical approach were preferred depending on localization and severity of stenosis, respiratory function at admission, severity of concomitant diseases and possibility of prolonged head adduction, presence of tracheostomy and cervical tissues inflammation, functional state of laryngeal structures.

RESULTS

Single-stage circular tracheal resection was applied in 44 (44.4 %) out of 99 cases. In 55 (55.6%) patients staged approach was preferred: Montgomery T-tube placement followed by tracheoplasty after 6-12 months - 27 patients; tracheoplasty on prefabricated endotracheal stent - 8 patients; staged endotracheal treatment (including Dumon prosthesis deployment) - 12 patients. In 11 cases circular resection was done as a final stage of treatment. There was no in-hospital mortality after circular tracheal resection. Morbidity included anastomotic dehiscence - 2 (3.6%), recurrent stenosis in 6 months after surgery - 1 (1.8%), granulation tissue growth followed by stenosis - 4 (7.3%), wound infection - 3 (5.5%) cases), postoperative pneumonia - 2 (3.6%) patients, respectively.

CONCLUSION

Tracheal resection is preferred for tracheal stenosis management. Alternative techniques are life-saving procedures, but could potentially extent the length of stenosis and delay recovery of the patient.

[Tracheolaryngeal resection for cicatricle stenosis]

AIM

To determine the safest and the most effective surgical treatment of patients with cicatricle stenosis of tracheolaryngeal segment via analysis of different approaches.

MATERIAL AND METHODS

For the period 1963-2015 at Petrovsky Russian Research Center for Surgery and Sechenov First Moscow State Medical University 1128 patients with cicatricle tracheal stenosis have been treated. There were 683 men and 445 women. 684 (60.6%) patients were young and the most employable (21-50 years). All patients were divided into 2 groups depending on time of treatment: the first one included 297 patients between 1963 and 2000, the second group - 831 patients between 2001 and 2015. In group 1 tracheolaryngeal anastomosis was made in 10 (16.9%) out of 59 patients who underwent tracheal resection. Previously indication for this surgery was cicatricle stenosis of cervical trachea and larynx with upper borderline of cicatricle changes at least 2 cm from vocal folds. In group 2 these procedures were more frequent. 94 (28.5%) out of 330 patients underwent tracheolaryngeal resection. Cranial borderline of lesion was within 0.5 cm from the vocal folds (only if posterior laryngeal wall at the level of cricoid cartilage was intact). Difficult patients are those who need for double-level or redo repair and procedures with tracheostomy.

RESULTS

In the second group overall morbidity after tracheal resections followed by anastomosis was 5.6%. These complications were more common after tracheolaryngeal anastomosis (17%). There were no lethal outcomes after 94 tracheolaryngeal resections. Good long-term results were observed in 89.8% of patients after circular resection. Their quality of life was similar to that of healthy people. Preserved cicatricle tracheal segments during tracheal repair with T-shaped airway tube adversely affects quality of life in these patients in long-term period.

Endoscopic and Surgical Treatment of Benign Tracheal Stenosis: A Multidisciplinary Team Approach

Purpose: Surgical resection and reconstruction are considered the most appropriate approaches to treat post-intubation tracheal stenosis (PITS). Bronchoscopic methods can be utilized as palliative therapy in patients who are ineligible for surgical treatment or who develop post-surgical re-stenosis. We investigated treatment outcomes in patients with benign tracheal stenosis.

Methods: A retrospective review was performed in patients who were diagnosed with PITS. Tracheal resection was performed for operable cases, whereas endoscopic interventions were preferred for inoperable cases with a complex or simple stenosis.

Results: In total, 42 patients (23 treated by bronchoscopic methods, 19 treated by surgery) took part in this study. No significant differences were observed in segment length, the proportion of obstructed airways, or vocal cord distance between the two groups. In all, 15 patients in the bronchoscopic treatment group received a stent. Following the intervention, the cure rates in the bronchoscopic and surgical treatment groups were 43.47% and 94.7%, respectively. A multidisciplinary approach resulted in a cure or satisfactory outcome in 90.5% of the patients while failure was noted in 9.5% of the patients.

Conclusion: Bronchoscopic methods are associated with a lower cure rate compared to surgery. A multidisciplinary approach was helpful for treatment planning in patients with PITS.

Principles and indications of extracorporeal life support in general thoracic surgery

The role of extracorporeal life support (ECLS) has expanded rapidly over the past 15 years to become an important tool in advanced general thoracic surgery practice. Intra-operative and in some cases continued post-operative ECLS is redefining the scope of complex surgical care. ECLS encompasses a spectrum of temporary mechanical support that may remove CO₂, oxygenate or provide hemodynamic support or a combination thereof. The most common modalities used in general thoracic surgery include extracorporeal membrane oxygenation (ECMO), interventional lung assist device (iLA^® Novalung^®, Heilbronn, Germany), and extracorporeal CO₂ removal (ECCO₂R). The ECMO and Novalung^® devices can be used in different modes for the short term or long-term support depending on the situation. In this review, the principles and current applications of ECLS in general thoracic surgery are presented.

Tracheal release maneuvers

Tracheal resection and reconstruction has been slow to develop in the field of thoracic surgery. The ability to perform a low tension, well-vascularized anastomosis with good outcomes has improved with understanding of tracheal blood supply and the ability to perform tracheal release maneuvers. Laryngeal and suprahyoid release maneuvers can be helpful for cervical tracheal resections, while hilar and pericardial release maneuvers can be beneficial in thoracic tracheal resections. Simple maneuvers such as neck flexion and dissection of the avascular pretracheal plane can also be used to improve anastomotic tension. In this paper, we will review the indications, technical considerations and results of performing cervical and intrathoracic tracheal release maneuvers during tracheal resection and reconstruction.

Initial Load Stability of Different Trachea Suture Techniques: Tests on an Ex Vivo Model

Objective Tracheal anastomosis can be performed with different suture techniques. In this experimental work, the resilience of anastomotic techniques to pressure and tensile stress was studied. Study Design Ex vivo pig model. Setting Experimental. Subjects and Methods The trachea with the 2 main bronchi in freshly slaughtered pigs was isolated and intubated (CH 8.0). Both main bronchi were closed distally by a stapler. After resection of the trachea, an anastomosis (n = 15 per group) was created: group 1, single interrupted sutures; group 2, continuous running suture; group 3, mixed technique. A continuous tensile stress of 0, 500, 1000, or 1500 g was applied to the preparations. Mechanical ventilation with a maximum pressure of 70 mbar was initiated. The airtightness of the anastomosis was verified by submerging the entire preparation under water. Results At tensile loads of 0.5 and 1.0 kg, all anastomoses created in the single-stitch technique were airtight; at 1.5 kg, 93.3% were without leaks. In the continuous suture technique, the airtightness of anastomoses decreased with increasing tensile load: from 93.3% at 500 g to 73.3% at 1 kg and 66.6% at 1.5 kg ( P = .02 at 1.5 kg). Anastomoses in the mixed technique were airtight in 80% at 500 g, 66.6% at 1 kg, and 46.6% at 1.5 kg ( P = .01 in comparison with single stitches). Conclusion Anastomoses created with single interrupted sutures showed the highest resilience against combined pressure and tensile stress.

Successful resection of a tracheal metastasis of rectal cancer: a case report

A tracheal metastasis (TM) from non-pulmonary malignancy is extremely rare, and there are very few reports regarding TM. Here, we report a case of the successful tracheal resection of TM of colorectal cancer. A 36-year-old man underwent a surgical resection for the rectal cancer. Approximately 5 years after the surgical resection of the primary rectal cancer, an isolated TM was identified. The patient was successfully treated with a tracheal resection. In conclusion, the current case suggested that the best treatment of the isolated TM might be a surgical resection.

Complications from tracheal resection for thyroid carcinoma

Thyroidectomy associated to en bloc tracheal resection with end-to-end anastomosis is the treatment of choice of thyroid tumor invading the tracheal wall and is associated with a good prognosis. However, the postoperative morbidity is not irrelevant. The present review aims to discuss the complications occurring after this aggressive surgical procedure. The search was performed using PubMed through an overarching for the following terms: "complication of tracheal resection [AND] invasive thyroid cancer". Postoperative complications rate after tracheal sleeve resection with end-to-end anastomosis for thyroid cancer invading tracheal wall range from 15% to 39%. Postoperative mortality is about 1.2%. The most common postoperative complications are: anastomotic dehiscence, airway stenosis, infections and bleeding. Tumor local recurrence can be considered a late on set complication. To conclude, in locally invasive thyroid cancer, en bloc resection of the thyroid with the tracheal segment interested by the tumor provides a good prognosis despite the non-negligible postoperative morbidity rate. Patients' selection and accurate surgical technique performing a tracheal tension-free anastomosis are mandatory to reduce postoperative morbidity and mortality.

Anesthetic Management of a Patient With Tracheal Dehiscence Post-Tracheal Resection Surgery

We present a case of a patient with complete tracheal dehiscence and multiple false passages after recent tracheal resection and anastomosis. Loss of tracheal continuity after disruption of anastomosis with distal stump retraction presents a unique anesthetic challenge given lack of access to the trachea and the need for adequate anesthesia and analgesia for surgical neck dissection. Traditional airway management, including awake fiberoptic intubation, intubation via direct laryngoscopy, needle cricothyrotomy, and awake tracheostomy are not viable options. Using total intravenous anesthesia with spontaneous ventilation, surgeons dissected the neck, retrieved the distal tracheal stump, repaired the trachea, and formalized the tracheostomy. We highlight the importance of recognizing the symptoms of a tracheal rupture, understanding the extreme limitation of securing the airway with traditional techniques, and discuss the alternative techniques including use of extracorporeal membrane oxygenation to avoid airway management. Awareness of increased mortality risk with tracheal reoperation and the significance of close communication between the anesthesiologists, the surgeons, and the patient is necessary for successful management.