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End-to-end anastomosis in chronic tracheal stenosis
Auris, Nasus, Larynx 30 (2003) S69 /S73 www.elsevier.com/locate/anl
End-to-end anastomosis in chronic tracheal stenosis Isao Kato a, Hiroya Iwatake a, Kouichiro Tsutsumi a,*, Izumi Koizuka a, Hachiro Suzuki b, Tadashi Nakamura b a
Department of Otolaryngology, St. Marianna University School of Medicine, 2-16-1 Sugao, Miyamae-ku, Kawasaki 216-8511, Japan b Department of Otolaryngology, Yamagata University School of Medicine, Yamagata 990-8585, Japan
Abstract Objective: This study assessed the efficacy and safety of end-to-end anastomosis of the trachea following segmental resection in chronic tracheal stenosis. Methods: End-to-end anastomoses of the trachea were performed in 35 patients with chronic tracheal stenosis; 18 patients with tracheal invasion of thyroid cancer and 17 patients with long-term intubation and blunt injuries of the trachea. Results: All operations were successful, except one whose unilateral recurrent nerve had not been identified in the recurrent thyroid cancer invasion with trachea. Conclusion: This operation provides a one-step cure for the stenosed trachea and can be applied to the resection of less than six tracheal segments. # 2002 Elsevier Science Ireland Ltd. All rights reserved. Keywords: Tracheal stenosis; End-to-end anastomosis; Chronic
1. Introduction Laryngotracheal injuries are often caused by traffic accidents [1], although their incidence has reduced as more people use seat belts [2]. Tracheostomy and endotracheal intubation are often performed as emergency procedures in patients with chronic respiratory failure [3]. Recently, the incidence of iatrogenic induction of chronic tracheal stenosis has increased. Various treatments have been reported, with the most appropriate being selected on a case-by-case basis, since each has particular advantages and disadvantages [4]. We report good results of tracheal resection followed by end-to-end anastomosis in 35 cases of chronic tracheal stenosis, comprising 18 with thyroid cancer and 17 with postintubational or blunt trauma.
2. Methods Eighteen and 17 cases of chronic tracheal stenosis were treated in Yamagata University School of Medi-
* Corresponding author. Tel.: /81-44-9778-111; fax: /81-44-9768748 E-mail address: [email protected] (K. Tsutsumi).
cine and St. Marianna University School of Medicine, respectively. Fourteen cases were males and 21 cases were females and their ages ranged from 18 to 71 years (mean 48 years). Tracheal stenosis was caused by endotracheal intubation in 12 cases and by tracheostomy in five cases. The period of tracheotomy was in the range from 3 weeks to 6 months. Ten cases with thyroid cancer were operated at the Yamagata University School of Medicine and eight cases were treated in St. Marianna University School of Medicine. Histology revealed papillary adenocarcinoma in 33 cases and medullary adenocarcinoma and poorly differentiated papillary adenocarcinoma in one case each.
3. Operative methods A horizontal skin incision is made at the level of the tracheostoma and extended laterally to the anterior borders of the sternocleidomastoid muscle. The skin flap is elevated in the subplatysmal layer. The strap muscles are divided along in the midline and the cervical trachea is exposed. The dissection is carried around the sides of the trachea to the posterior ends of the tracheal cartilages for one ring below and one ring above the stenosis. A sharp dissection is performed to dissect the inside of the tracheal sheath in order to avoid injury to
0385-8146/02/$ - see front matter # 2002 Elsevier Science Ireland Ltd. All rights reserved. PII: S 0 3 8 5 - 8 1 4 6 ( 0 2 ) 0 0 1 2 0 - 7
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the recurrent laryngeal nerves [5]. The trachea is carefully incised at the stenosis whilst observing the tracheal lumen. It is partially incised segment by segment until normal tracheal lumen is observed both below and above the stenosis, at which time the resection is carried out through the membranous portion of the trachea. The laryngeal release then commences. Another skin incision is made at the level of the hyoid bone. After the body of the hyoid bone is exposed, the mylohyoid, geniohyoid and genioglossus muscles are transected from it. The stylohyoid muscles are transected at the inner side of the digastric muscles and the hyoid bone is transected just interior to the greater cornua, separating the body from the greater cornua. Thus, the larynx will descend sufficiently inferiorly when using this procedure [3]. Before approximation of the cut ends, reintubation is performed through the oral side. After intubation, end-to-end anastomosis is performed with Maxon 3-0 sutures. Posteriorly, the sutures are placed through the full thickness of the trachea, including the mucosal and submucosal layers. The lateral and anterior walls of the transected tracheas are sutured in the submucosal layers. The endotracheal tube is drawn and placed above the anastomosis site to see if air leakage is present. Postoperatively, the patients remained positioned with their neck flexed anteriorly for 2 /3 days.
4. Case reports A 26-year-old male was admitted to our hospital complaining of dyspnea. He had fallen into respiratory failure following surgery in the hospital, which had been treated with intubation by a cuffed tube for 9 days and intermittent, positive-pressure ventilation. A laryngoscopic examination showed circumscribed stenosis with :/4 mm of lumen in the subglottis. Computed tomography of the larynx revealed subglottic stenoses as long as 1.5 cm (Fig. 1, left). Respiratory function tests showed that FEV 1.0 was 0.85 l, the percentage of FEV represented by FEV 1.0 (% FEV 1.0) was 22.5% and the flow /volume curve exhibited the flat pattern of severe superior tracheal stenosis (Fig. 2, left). He suddenly became severely dyspneic and cyanotic when coughing. An emergency tracheostomy was performed between the fifth and sixth tracheal ring. After recovery in the constitutional state, tracheal resection was first followed by end-to-end anastomosis of the trachea. Surgery revealed that the lower half of the posterior cricoid plate was missing and that web protruded between the cricoid and first tracheal ring, showing only a match-head-sized hole in the center (Fig. 3). Endto-end anastomosis after the resection of three tracheal rings was performed successfully. The patient had been well postoperatively, but 5 months later he noticed slight stridor on exertion. Fiberscopic findings showed a
Fig. 1. Computed tomography of the trachea shows circumscribed stenosis (left, arrow) before surgery, which remained patent after surgery (right).
posteriorly based web in the suture ends, which were treated with a silicone T-tube for a period of 8 weeks. Since extubation, he has not shown any sign of dyspnea for 2 years (Fig. 1, right). The respiratory function tests improved as follows: FEV 1.0, 4.06 l; %FEV 1.0, 85.1%; and normal flow /volume curve (Fig. 2, right). A 58-year-old man noticed a lump in the anterior neck at the left thyroid level. This was found to be a papillary adenocarcinoma and was dissected away partially to leave a right normal gland. He had been well for 3 years when he noticed hoarseness and coughing was accompanied with bloody sputum. Fiberscopy confirmed left recurrent nerve paralysis and tumor growth in the subglottis of the cricoid region. The anterior cricoid arch was dissected and extended along with cricothyroid membrane to the posterior lamina, finally dissecting half of the cricoid, the dissected segment of which included tumor with a safety margin of :/3 mm (Fig. 4). The first and second trachea was designed in order to produce a side wall that was anastomed to the thyroid cartilage (Fig. 5A, B). An endto-end anastomosis was performed over a spongerubber-packed rubber finger from an operative glove, which was removed under endoscopy 1 week later. A 64-year-old female noticed a mass in her neck which progressively grew enough to shift the airway from the left side neck. A solid and immovable 6 /8-cm tumor could be palpated from the cricoid down to the sternal notch. An X-ray film revealed the trachea to be shifted and curved to the right and it was found to be stiff and irregular on the left wall (Fig. 6, left). During surgery, the tumor was found to be larger and more adhesive to both the trachea and esophagus than anticipated. In spite of careful dissection of the tumor, the esophagus was found torn and open. The esophagus was replaced by a stomach roll after the recurrent nerve had been traced downward to the carina and end-to-end
I. Kato et al. / Auris, Nasus, Larynx 30 (2003) S69 /S73
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Fig. 2. Respiratory function: FEV 1.0 is 0.85 l,% FEV 1.0 is 22.5% and the flow /volume curve is flat, indicating severe superior tracheal stenosis (A). Postoperative curve: FEV 1.0 is 4.06 l,% FEV1.0 is 85.1% and the flow /volume curve is normal (B).
Fig. 4. Laryngofissure through thyroid cartilage extends to the anterior cricoid (Cr), finally dissecting half of the cricoid, which includes the tumor (T).
anastomosis was performed after the anterolateral cricoid arch was partially excised (Fig. 7). The vocal cords were mobile on the right (Fig. 6, right) and remained unchanged after operation (Fig. 6, right). A histological examination revealed poorly differentiated papillary adenocarcinoma with squamous metaplasia.
5. Results
Fig. 3. Resected three tracheal rings show circumscribed stenosis with :/4 mm of lumen in the subglottis, continuing as far as 1.5 cm.
All cases were operated with tracheal resection followed by end-to-end anastomosis of the trachea, with the range of resection varying from three to six
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Fig. 5. The first and second trachea is designed so as to produce a side wall (A) which is anastomosed to the thyroid cartilage (B).
tracheal rings. The recurrent laryngeal nerves remained intact in all cases. Neither aspiration nor dysphasia was observed, except for one case whose recurrent nerve in the opposite side could not be identified and was paralyzed. In all cases, the airway was kept patent without dyspnea. However, one case (the first performed) showed granulation regrowth at the suture end, which was treated successfully with a silicone Ttube. The third case died from pleural effusion associated with lung metastasis 6 months later.
Fig. 7. End-to-end anastomosis is performed after the torn and open esophagus was replaced by a stomach roll and the left anterolateral cricoid arch was partially excised and six segments were transected.
6. Discussion Improvements in respiratory techniques and instrumentation have lead to more lives being saved, but this has resulted in a concomitant increase in the number of cases with stenosis resulting from intubation. The
Fig. 6. Trachea shifted by a tumor (left) returns to the normal position after surgery (right).
I. Kato et al. / Auris, Nasus, Larynx 30 (2003) S69 /S73
possible causes are as follows: (1) inappropriate tube size; (2) excessive cuff pressure; (3) tracheal infection; (4) inappropriate positioning of cuffed tube; and (5) longterm intubation and large amounts of steroid used in respiratory management [6]. The maximum acceptable intubation periods have varied greatly in previous reports: from 8 to 12 h [7]to 1 week [8]. However, we consider that tracheostomy within 24 h (or 48 h at the latest) would be preferable when long-term intubation is anticipated. A variety of treatments for tracheal stenosis have been reported, as follows: (1) end-to-end anastomosis of the trachea; (2) multistep reconstruction of the tracheal window; (3) laser surgery; (4) silicone T-tube intubation; and (5) tracheoplasty. Since each procedure has its own advantages and disadvantages, the most appropriate one in each case is selected according to the patient’s age and the grade and area of stenosis [3]. End-to-end anastomosis of the trachea that we applied is physiological and enables the trachea to be reconstructed primarily; we therefore regarded it as one of the best methods. End-to-end anastomosis of the trachea is a common procedure since it can be performed even after excision of 60% of the trachea [9,10]. Several aspects of this procedure are as follows. Firstly, there are two methods for performing laryngeal mobilization in order to appose the cut ends without significant tension: (1) Dedo et al. [11] cut the thyrohyoid membrane, whereas (2) Montgomery [3] cut the suprahyoid muscles and split the inside of the greater cornua of the hyoid bone. It was pointed out that dysphasia frequently occurs after surgery involving infrahyoid laryngeal release. Kato et al. [12] compared both techniques and reported that suprahyoid laryngeal release is much simpler and quicker because important vessels and nerves are not present in the suprahyoid region and difficulties with deglutition did not occur after the surgery. We have also applied the method of cutting on the hyoid bone and have never experienced cases with aspiration. Secondly, the recurrent laryngeal nerves run outside the tracheal sheath, so they can be kept intact by sharply dissecting the inside of the tracheal sheath [5]. Thirdly, the inferior thyroid artery provides a segmental blood supply to the upper half of the trachea [13]. Therefore, it is important to dissect around the trachea only 1 cm above and below the presumed tracheal cut ends [6]. In addition, when carrying our end-to-end anastomosis, the method of initial tracheostomy should be considered carefully. Tracheostomy by a horizontal tracheal incision is the method we usually perform, since it is superior to the circular or U-shaped tracheal incision in that it minimizes damage to the tracheal cartilages [14].
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7. Conclusion We have achieved favorable results when performing tracheal resection followed by end-to-end anastomosis in 35 cases with tracheal stenosis after intubation or tracheostomy and thyroid cancer involving the trachea. It is expected that the incidence of cases with tracheal stenosis will increase concomitantly with anticipated future increases in long-term respiratory management. It is important to pay the greatest attention to tracheostomy techniques and the management of cannulas and ischemia induced by cuffed tubes. We consider that endto-end anastomosis of the trachea, which is the most physiological technique and one that is well established, is the most efficient.
Acknowledgements The authors would like to thank Masako Osakabe for her secretarial help.
References [1] Ogura JH, Powers WE. Functional restitution of traumatic stenosis of the larynx and pharynx. Laryngoscope 1964;74:1081 /110. [2] Ogura JH, Biller HF. Reconstruction of the larynx following blunt trauma. Ann Otol 1971;80:492 /506. [3] Montgomery WW. Suprahyoid release for tracheal anastomosis. Arch Otol 1974;99:255 /60. [4] Pearson FG, Andrews MJ. Detection and management of tracheal stenosis following cuffed tube tracheotomy. Ann Thor Surg 1971;12:359 /74. [5] Sarrazin R. Mediastinoscopy. Germany: Odense University, 1971. [6] Pearson FG, Goldberg M, da Silvia AJ. Tracheal stenosis complicating tracheostomy with cuffed tubes. Arch Surg 1968;97:380 /94. [7] Harrison GA, Tonkin JP. Prolonged (therapeutic) endotracheal intubation. Br J Anaesth 1968;40:241 /9. [8] Aass AS. Complication to tracheostomy and long-term intubation: a follow-up study. Acta Anaesth Scand 1975;19:127 /33. [9] Grillo HC, Dignan EF, Miura T. Extensive resection and reconstruction of mediastinal trachea without prosthesis or graft. J Thor Cardiovasc Surg 1964;48:741 /9. [10] Neaf AP. Tracheobronchial reconstruction. Ann Thor Surg 1973;15:301 /12. [11] Dedo HH, Fishman NH. Laryngeal release and sleeve resection for tracheal stenosis. Ann Otol Rhinol Laryngol 1969;78:285 /9. [12] Kato I, Koike Y, Kimura Y, Suzuki H. End-to-end anastomosis of the cervical trachea. Otolaryngology (Tokyo) 1979;51:955 /63 (in Japanese). [13] Miura T, Grillo HC. The contribution of the inferior thyroid artery to the blood supply of the human trachea. Surg Gynec Obstet 1966;123:99 /102. [14] Kato I, Uesugi K, Kikuchihara M, Iwasawa H, Iida J, Tsutsumi K, Iwatake H, Takeyama I. Tracheostomy */the horizontal tracheal incision. J Laryngol Otol 1990;104:322 /5.
End-to-end anastomosis in chronic tracheal stenosis Isao Kato a, Hiroya Iwatake a, Kouichiro Tsutsumi a,*, Izumi Koizuka a, Hachiro Suzuki b, Tadashi Nakamura b a
Department of Otolaryngology, St. Marianna University School of Medicine, 2-16-1 Sugao, Miyamae-ku, Kawasaki 216-8511, Japan b Department of Otolaryngology, Yamagata University School of Medicine, Yamagata 990-8585, Japan
Abstract Objective: This study assessed the efficacy and safety of end-to-end anastomosis of the trachea following segmental resection in chronic tracheal stenosis. Methods: End-to-end anastomoses of the trachea were performed in 35 patients with chronic tracheal stenosis; 18 patients with tracheal invasion of thyroid cancer and 17 patients with long-term intubation and blunt injuries of the trachea. Results: All operations were successful, except one whose unilateral recurrent nerve had not been identified in the recurrent thyroid cancer invasion with trachea. Conclusion: This operation provides a one-step cure for the stenosed trachea and can be applied to the resection of less than six tracheal segments. # 2002 Elsevier Science Ireland Ltd. All rights reserved. Keywords: Tracheal stenosis; End-to-end anastomosis; Chronic
1. Introduction Laryngotracheal injuries are often caused by traffic accidents [1], although their incidence has reduced as more people use seat belts [2]. Tracheostomy and endotracheal intubation are often performed as emergency procedures in patients with chronic respiratory failure [3]. Recently, the incidence of iatrogenic induction of chronic tracheal stenosis has increased. Various treatments have been reported, with the most appropriate being selected on a case-by-case basis, since each has particular advantages and disadvantages [4]. We report good results of tracheal resection followed by end-to-end anastomosis in 35 cases of chronic tracheal stenosis, comprising 18 with thyroid cancer and 17 with postintubational or blunt trauma.
2. Methods Eighteen and 17 cases of chronic tracheal stenosis were treated in Yamagata University School of Medi-
* Corresponding author. Tel.: /81-44-9778-111; fax: /81-44-9768748 E-mail address: [email protected] (K. Tsutsumi).
cine and St. Marianna University School of Medicine, respectively. Fourteen cases were males and 21 cases were females and their ages ranged from 18 to 71 years (mean 48 years). Tracheal stenosis was caused by endotracheal intubation in 12 cases and by tracheostomy in five cases. The period of tracheotomy was in the range from 3 weeks to 6 months. Ten cases with thyroid cancer were operated at the Yamagata University School of Medicine and eight cases were treated in St. Marianna University School of Medicine. Histology revealed papillary adenocarcinoma in 33 cases and medullary adenocarcinoma and poorly differentiated papillary adenocarcinoma in one case each.
3. Operative methods A horizontal skin incision is made at the level of the tracheostoma and extended laterally to the anterior borders of the sternocleidomastoid muscle. The skin flap is elevated in the subplatysmal layer. The strap muscles are divided along in the midline and the cervical trachea is exposed. The dissection is carried around the sides of the trachea to the posterior ends of the tracheal cartilages for one ring below and one ring above the stenosis. A sharp dissection is performed to dissect the inside of the tracheal sheath in order to avoid injury to
0385-8146/02/$ - see front matter # 2002 Elsevier Science Ireland Ltd. All rights reserved. PII: S 0 3 8 5 - 8 1 4 6 ( 0 2 ) 0 0 1 2 0 - 7
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I. Kato et al. / Auris, Nasus, Larynx 30 (2003) S69 /S73
the recurrent laryngeal nerves [5]. The trachea is carefully incised at the stenosis whilst observing the tracheal lumen. It is partially incised segment by segment until normal tracheal lumen is observed both below and above the stenosis, at which time the resection is carried out through the membranous portion of the trachea. The laryngeal release then commences. Another skin incision is made at the level of the hyoid bone. After the body of the hyoid bone is exposed, the mylohyoid, geniohyoid and genioglossus muscles are transected from it. The stylohyoid muscles are transected at the inner side of the digastric muscles and the hyoid bone is transected just interior to the greater cornua, separating the body from the greater cornua. Thus, the larynx will descend sufficiently inferiorly when using this procedure [3]. Before approximation of the cut ends, reintubation is performed through the oral side. After intubation, end-to-end anastomosis is performed with Maxon 3-0 sutures. Posteriorly, the sutures are placed through the full thickness of the trachea, including the mucosal and submucosal layers. The lateral and anterior walls of the transected tracheas are sutured in the submucosal layers. The endotracheal tube is drawn and placed above the anastomosis site to see if air leakage is present. Postoperatively, the patients remained positioned with their neck flexed anteriorly for 2 /3 days.
4. Case reports A 26-year-old male was admitted to our hospital complaining of dyspnea. He had fallen into respiratory failure following surgery in the hospital, which had been treated with intubation by a cuffed tube for 9 days and intermittent, positive-pressure ventilation. A laryngoscopic examination showed circumscribed stenosis with :/4 mm of lumen in the subglottis. Computed tomography of the larynx revealed subglottic stenoses as long as 1.5 cm (Fig. 1, left). Respiratory function tests showed that FEV 1.0 was 0.85 l, the percentage of FEV represented by FEV 1.0 (% FEV 1.0) was 22.5% and the flow /volume curve exhibited the flat pattern of severe superior tracheal stenosis (Fig. 2, left). He suddenly became severely dyspneic and cyanotic when coughing. An emergency tracheostomy was performed between the fifth and sixth tracheal ring. After recovery in the constitutional state, tracheal resection was first followed by end-to-end anastomosis of the trachea. Surgery revealed that the lower half of the posterior cricoid plate was missing and that web protruded between the cricoid and first tracheal ring, showing only a match-head-sized hole in the center (Fig. 3). Endto-end anastomosis after the resection of three tracheal rings was performed successfully. The patient had been well postoperatively, but 5 months later he noticed slight stridor on exertion. Fiberscopic findings showed a
Fig. 1. Computed tomography of the trachea shows circumscribed stenosis (left, arrow) before surgery, which remained patent after surgery (right).
posteriorly based web in the suture ends, which were treated with a silicone T-tube for a period of 8 weeks. Since extubation, he has not shown any sign of dyspnea for 2 years (Fig. 1, right). The respiratory function tests improved as follows: FEV 1.0, 4.06 l; %FEV 1.0, 85.1%; and normal flow /volume curve (Fig. 2, right). A 58-year-old man noticed a lump in the anterior neck at the left thyroid level. This was found to be a papillary adenocarcinoma and was dissected away partially to leave a right normal gland. He had been well for 3 years when he noticed hoarseness and coughing was accompanied with bloody sputum. Fiberscopy confirmed left recurrent nerve paralysis and tumor growth in the subglottis of the cricoid region. The anterior cricoid arch was dissected and extended along with cricothyroid membrane to the posterior lamina, finally dissecting half of the cricoid, the dissected segment of which included tumor with a safety margin of :/3 mm (Fig. 4). The first and second trachea was designed in order to produce a side wall that was anastomed to the thyroid cartilage (Fig. 5A, B). An endto-end anastomosis was performed over a spongerubber-packed rubber finger from an operative glove, which was removed under endoscopy 1 week later. A 64-year-old female noticed a mass in her neck which progressively grew enough to shift the airway from the left side neck. A solid and immovable 6 /8-cm tumor could be palpated from the cricoid down to the sternal notch. An X-ray film revealed the trachea to be shifted and curved to the right and it was found to be stiff and irregular on the left wall (Fig. 6, left). During surgery, the tumor was found to be larger and more adhesive to both the trachea and esophagus than anticipated. In spite of careful dissection of the tumor, the esophagus was found torn and open. The esophagus was replaced by a stomach roll after the recurrent nerve had been traced downward to the carina and end-to-end
I. Kato et al. / Auris, Nasus, Larynx 30 (2003) S69 /S73
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Fig. 2. Respiratory function: FEV 1.0 is 0.85 l,% FEV 1.0 is 22.5% and the flow /volume curve is flat, indicating severe superior tracheal stenosis (A). Postoperative curve: FEV 1.0 is 4.06 l,% FEV1.0 is 85.1% and the flow /volume curve is normal (B).
Fig. 4. Laryngofissure through thyroid cartilage extends to the anterior cricoid (Cr), finally dissecting half of the cricoid, which includes the tumor (T).
anastomosis was performed after the anterolateral cricoid arch was partially excised (Fig. 7). The vocal cords were mobile on the right (Fig. 6, right) and remained unchanged after operation (Fig. 6, right). A histological examination revealed poorly differentiated papillary adenocarcinoma with squamous metaplasia.
5. Results
Fig. 3. Resected three tracheal rings show circumscribed stenosis with :/4 mm of lumen in the subglottis, continuing as far as 1.5 cm.
All cases were operated with tracheal resection followed by end-to-end anastomosis of the trachea, with the range of resection varying from three to six
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Fig. 5. The first and second trachea is designed so as to produce a side wall (A) which is anastomosed to the thyroid cartilage (B).
tracheal rings. The recurrent laryngeal nerves remained intact in all cases. Neither aspiration nor dysphasia was observed, except for one case whose recurrent nerve in the opposite side could not be identified and was paralyzed. In all cases, the airway was kept patent without dyspnea. However, one case (the first performed) showed granulation regrowth at the suture end, which was treated successfully with a silicone Ttube. The third case died from pleural effusion associated with lung metastasis 6 months later.
Fig. 7. End-to-end anastomosis is performed after the torn and open esophagus was replaced by a stomach roll and the left anterolateral cricoid arch was partially excised and six segments were transected.
6. Discussion Improvements in respiratory techniques and instrumentation have lead to more lives being saved, but this has resulted in a concomitant increase in the number of cases with stenosis resulting from intubation. The
Fig. 6. Trachea shifted by a tumor (left) returns to the normal position after surgery (right).
I. Kato et al. / Auris, Nasus, Larynx 30 (2003) S69 /S73
possible causes are as follows: (1) inappropriate tube size; (2) excessive cuff pressure; (3) tracheal infection; (4) inappropriate positioning of cuffed tube; and (5) longterm intubation and large amounts of steroid used in respiratory management [6]. The maximum acceptable intubation periods have varied greatly in previous reports: from 8 to 12 h [7]to 1 week [8]. However, we consider that tracheostomy within 24 h (or 48 h at the latest) would be preferable when long-term intubation is anticipated. A variety of treatments for tracheal stenosis have been reported, as follows: (1) end-to-end anastomosis of the trachea; (2) multistep reconstruction of the tracheal window; (3) laser surgery; (4) silicone T-tube intubation; and (5) tracheoplasty. Since each procedure has its own advantages and disadvantages, the most appropriate one in each case is selected according to the patient’s age and the grade and area of stenosis [3]. End-to-end anastomosis of the trachea that we applied is physiological and enables the trachea to be reconstructed primarily; we therefore regarded it as one of the best methods. End-to-end anastomosis of the trachea is a common procedure since it can be performed even after excision of 60% of the trachea [9,10]. Several aspects of this procedure are as follows. Firstly, there are two methods for performing laryngeal mobilization in order to appose the cut ends without significant tension: (1) Dedo et al. [11] cut the thyrohyoid membrane, whereas (2) Montgomery [3] cut the suprahyoid muscles and split the inside of the greater cornua of the hyoid bone. It was pointed out that dysphasia frequently occurs after surgery involving infrahyoid laryngeal release. Kato et al. [12] compared both techniques and reported that suprahyoid laryngeal release is much simpler and quicker because important vessels and nerves are not present in the suprahyoid region and difficulties with deglutition did not occur after the surgery. We have also applied the method of cutting on the hyoid bone and have never experienced cases with aspiration. Secondly, the recurrent laryngeal nerves run outside the tracheal sheath, so they can be kept intact by sharply dissecting the inside of the tracheal sheath [5]. Thirdly, the inferior thyroid artery provides a segmental blood supply to the upper half of the trachea [13]. Therefore, it is important to dissect around the trachea only 1 cm above and below the presumed tracheal cut ends [6]. In addition, when carrying our end-to-end anastomosis, the method of initial tracheostomy should be considered carefully. Tracheostomy by a horizontal tracheal incision is the method we usually perform, since it is superior to the circular or U-shaped tracheal incision in that it minimizes damage to the tracheal cartilages [14].
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7. Conclusion We have achieved favorable results when performing tracheal resection followed by end-to-end anastomosis in 35 cases with tracheal stenosis after intubation or tracheostomy and thyroid cancer involving the trachea. It is expected that the incidence of cases with tracheal stenosis will increase concomitantly with anticipated future increases in long-term respiratory management. It is important to pay the greatest attention to tracheostomy techniques and the management of cannulas and ischemia induced by cuffed tubes. We consider that endto-end anastomosis of the trachea, which is the most physiological technique and one that is well established, is the most efficient.
Acknowledgements The authors would like to thank Masako Osakabe for her secretarial help.
References [1] Ogura JH, Powers WE. Functional restitution of traumatic stenosis of the larynx and pharynx. Laryngoscope 1964;74:1081 /110. [2] Ogura JH, Biller HF. Reconstruction of the larynx following blunt trauma. Ann Otol 1971;80:492 /506. [3] Montgomery WW. Suprahyoid release for tracheal anastomosis. Arch Otol 1974;99:255 /60. [4] Pearson FG, Andrews MJ. Detection and management of tracheal stenosis following cuffed tube tracheotomy. Ann Thor Surg 1971;12:359 /74. [5] Sarrazin R. Mediastinoscopy. Germany: Odense University, 1971. [6] Pearson FG, Goldberg M, da Silvia AJ. Tracheal stenosis complicating tracheostomy with cuffed tubes. Arch Surg 1968;97:380 /94. [7] Harrison GA, Tonkin JP. Prolonged (therapeutic) endotracheal intubation. Br J Anaesth 1968;40:241 /9. [8] Aass AS. Complication to tracheostomy and long-term intubation: a follow-up study. Acta Anaesth Scand 1975;19:127 /33. [9] Grillo HC, Dignan EF, Miura T. Extensive resection and reconstruction of mediastinal trachea without prosthesis or graft. J Thor Cardiovasc Surg 1964;48:741 /9. [10] Neaf AP. Tracheobronchial reconstruction. Ann Thor Surg 1973;15:301 /12. [11] Dedo HH, Fishman NH. Laryngeal release and sleeve resection for tracheal stenosis. Ann Otol Rhinol Laryngol 1969;78:285 /9. [12] Kato I, Koike Y, Kimura Y, Suzuki H. End-to-end anastomosis of the cervical trachea. Otolaryngology (Tokyo) 1979;51:955 /63 (in Japanese). [13] Miura T, Grillo HC. The contribution of the inferior thyroid artery to the blood supply of the human trachea. Surg Gynec Obstet 1966;123:99 /102. [14] Kato I, Uesugi K, Kikuchihara M, Iwasawa H, Iida J, Tsutsumi K, Iwatake H, Takeyama I. Tracheostomy */the horizontal tracheal incision. J Laryngol Otol 1990;104:322 /5.