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Management of complications of tracheal surgery
Chest Surg Clin N Am 13 (2003) 385 – 397
Management of complications of tracheal surgery Michael Lanuti, MDa,b,*, Douglas J. Mathisen, MDa,b a
Massachusetts General Hospital, Blake 1570, 55 Fruit Street, Boston, MA 02114, USA b Harvard Medical School, 25 Shattuck Street, Boston, MA 02115, USA
Post-intubation tracheal injuries remain the most common indication for tracheal resection and reconstruction [1,2]. Meticulous attention to the details of intubation, the technique of tracheostomy, and postoperative care can avoid the development of complications of tracheal stenosis. Injury to the tracheal mucosa during intubation might predispose patients to the development of stenosis. Proper selection of tube sizes is essential for the prevention of laryngeal injury and injury to the subglottic area. Ischemic injury to the mucosa or the larynx or subglottis from overly large endotracheal tubes occurs more commonly in women, who tend to have smaller larynxes than men. Despite low-pressure tracheostomy cuffs, overinflation of endotracheal and tracheostomy cuffs might lead to injury and tracheal stenosis. Overinflation of low-pressure cuffs is responsible for a large number of tracheal stenoses. It is important to avoid excessive tension on tracheostomy tubes; excessive tension leads to excessive destruction of tracheal cartilages, increasing the likelihood of a stomal stenosis after removal of the tracheostomy tube. If another tracheotomy is needed to control the airway, it is imperative that the tracheostomy be placed through the most damaged portion of the trachea, thus preserving as much viable trachea as possible for future reconstruction.
High-risk patients There are certain circumstances that place patients at high risk for complications following tracheal resection and reconstruction. One of the most critical factors influencing the success of tracheal surgery is the absence of need for mechanical ventilation. The need for mechanical ventilation must be considered in high-risk
* Corresponding author. Michael Lanuti, MD, Massachusetts General Hospital, Blake 1570, 55 Fruit Street, Boston, MA 02114. E-mail address: [email protected] (M. Lanuti). 1052-3359/03/$ – see front matter D 2003, Elsevier Inc. All rights reserved. doi:10.1016/S1052-3359(03)00007-3
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groups such as quadriplegics and those affected by neuromuscular disorders associated with weakness. Mechanical ventilation following tracheal resection increases the risk of anastomotic complications and the possibility of dehiscence. Many patients are mistakenly treated with high-dose steroids for presumed adult-onset asthma. It is the authors’ belief that systemic steroids and some degree of anastomotic tension are associated with a greater risk of anastomotic dehiscence. It is therefore mandatory that patients be weaned from steroids before any surgical intervention. It is often necessary to dilate strictures or remove tumor bronchoscopically while steroids are being weaned. Prior radiation therapy ( > 5000 cGy completed over 12 months before planned resection) is also a relative contraindication. In certain highly selected patients, tracheal resection and reconstruction can be performed using a well-vascularized pedicle (eg, omentum) to encircle and buttress the anastomosis. Another important variable in tracheal resection is the condition of the tracheal mucosa. It is imperative that the tracheal mucosa be assessed. The presence of inflammation related to the underlying disease or recent surgical procedure (ie, tracheostomy, trauma, and laser) might dictate postponement of reconstruction until the process has subsided. Before reconstruction, a careful assessment of the glottis should be obtained to ensure an adequate glottic airway. It has been the authors’ practice to correct any glottic abnormalities before tracheal reconstruction. Postintubation injuries must be evaluated for tracheomalacia by way of awake flexible bronchoscopy or fluoroscopy. Malacia might be observed either proximal or distal to an area of stenosis, and it greatly influences the amount of trachea that is suitable for reconstruction. Patients with known Wegener’s granulomatosis and relapsing polychondritis are extremely unpredictable and are best treated with palliative measures rather than reconstruction.
Airway management Management of critical airway stenosis can be a formidable challenge. Understanding the principles of management might avoid ill-advised surgery and minimize potential complications. Emergency tracheal resection should be avoided. It is always preferable to stabilize the airway, properly evaluate the patient, and perform resection under ideal circumstances. Upon initial presentation, simple measures such as cool humidified mist, bed rest, head elevation, and cautious sedation are often helpful. As a substitute for oxygen, Heliox (BOC Gases, Murray Hill, NJ) is often helpful in the acute setting. The lower viscosity of Heliox is a great advantage in a stenotic airway. Any airway manipulation under local anesthesia—especially in the outpatient setting—could precipitate airway obstruction from secretions, hemorrhage, or swelling. If intervention is necessary, postintubation stenosis can be safely dilated under general anesthesia using dilators and rigid and flexible bronchoscopes [3]. The procedure is performed under direct visualization starting with a number 3.5 or 4 mm
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pediatric rigid bronchoscope, gradually increasing the size until a 7 or 8 mm adult rigid bronchoscope can be gently passed through the stenosis. Tumors can be cored out with biopsy forceps, rigid bronchoscopes, or with a laser. Intervention in this manner can stabilize the airway from a few days to weeks to allow further evaluation of a patient’s airway. Acute airway distress can develop following tracheal resection and reconstruction in some patients. The etiology of this distress might be glottic edema, inadequate airway following reconstruction, unrecognized glottic problems, malacia, or vocal cord paralysis. If the need for an airway is anticipated at the time of surgery, an uncuffed tracheostomy tube (#4 or #5) can be placed two rings below the tracheal anastomosis with proper coverage of the suture line with local tissues (eg, thyroid or cervical strap muscle). Alternatively, a small, uncuffed endotracheal tube can be left in place and removed 2 to 3 days later in the operating room with the patient under a light general anesthetic. If an inadequate airway still exists, a small tracheostomy tube can be placed at that time. Postoperative edema might compromise the airway. Edema of the larynx after tracheal reconstruction is initially treated with fluid restriction, racemic epinephrine, and a brief course of systemic steroids (24 –36 hours). If this treatment does not resolve the problem, it is best to intubate the patient over a small, uncuffed endotracheal tube. A brief period of time should be allowed for swelling to subside, then the patient should be evaluated in the operating room for intubation or tracheostomy as described previously.
Management of complications Complications of tracheal resection and reconstruction vary with the pathologic condition. As previously stated, the vast majority of operations are performed for postintubation stenosis. Resection of tracheal neoplasms is the next most common reconstruction performed. Reconstructions for infectious diseases, idiopathic stenosis, traumatic lesions, congenital deformities, and extrinsic compression present with special problems, but the general principles are the same. For tumors, the tracheal mucosa is usually normal, whereas for postintubation problems, the mucosa can have varying degrees of inflammation or fibrosis. The most comprehensive account of complications following tracheal resection was reported by Grillo and colleagues in 1986 [4], and updated in 1990 for resection of neoplasms [5] and for resection of postintubation stenosis in 1995 [6]. The results of this work form the basis of further discussions about complications of tracheal resection.
Results A total of 521 tracheal resections and reconstructions were performed on 503 patients. Thirteen patients had restenosis after an initial procedure and were
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reoperated at a later date. Five patients had immediate failure because of residual tracheal malacia and were reoperated within hours of their initial procedure. Evaluation of this cumulative patient series revealed a progressive increase in the complication rate as the anastomotic level ascended. The failure rates were 2.2% for trachea – trachea anastomosis, 6.0% for a trachea –cricoid anastomosis, and 8.1% for trachea –thyroid anastomosis (Fig. 1). Minor complications became more prevalent with each level, from 16% to 17.1% to 21%, respectively. The major complication rate did not appear to change (13.9%, 15.4%, and 12.9%, respectively). Complications can be divided into failures of incomplete diagnosis, failure of technique, and those not easily classified. Failures of incomplete diagnosis, which were limited largely to postintubation lesions, resulted from (1) failure to recognize incompetence of the glottis before tracheal repair, and (2) failure to recognize the extent of malacia present in addition to stenosis, a condition that requires intervention at the initial operation. A third problem identified in patients after prior operative failure was that the extent of stenosis had been unrecognized with an inadequate resection. The second group of complications contains failure of technique. Formation of granulation tissue at the anastomosis must be classified as an error in technique and in selection of patients. Separation of an anastomosis is (in most cases) because of excessive tension caused by resection of too much trachea or failure to perform relaxing maneuvers to lessen tension. Excessive circumferential dissection of the trachea, particularly distal to the point of division, might compromise the blood supply and result in separation or stenosis. Excessive resection is more likely to occur in the management of tumors. Partial or complete stenosis can occur at the anastomotic line. This phenomenon results from granulation tissue that gradually turns into cicatrizing circumferential scar or, more often, into partial separation. The latter can occur without clinical air leak because of tension
Fig. 1. Categories of reconstruction. (a) Trachea to trachea anastomosis after segmental tracheal resection. (b) Cricotracheal anastomosis where transaction is just below the cricoid cartilage, or where a portion of lower cricoid cartilage, usually anterior, has been resected. (c) Anastomosis of tailored trachea to thyroid cartilage or cricothyroid membrane anteriorly, where subglottic laryngeal involvement by stenosis required laryngoplasty.
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Table 1 Complications of operations for postintubation tracheal stenosis
Granulations (Before 1978) (After 1978) Dehiscence Laryngeal dysfunction Malacia Hemorrhage Edema (anastomotic) Infection Wound Pulmonary Myocardial infarction TEF Pneumothorax Line infection Atrial fibrillation Deep venous thrombosis Total
Major
Minor
Total
11 10 1 28 11 10 5 3
38 34 4 1 14 0 0 1
49 44 5 29 25 10 5 4
7 5 1 1 0 0 0 0 82
8 14 0 0 3 1 1 1 82
15 19 1 1 3 1 1 1 164
Data from Grillo HC, Donahue DM, Mathisen DJ, et al. Postintubation tracheal stenosis: treatment and results. J Thorac Cardiovasc Surg 1995;109:486 – 93.
over time. Complications following resection for postintubation stenosis are summarized in Table 1. Granulations In 49 patients, granulation tissue formed at the site of the tracheal anastomosis. Only five such cases out of 317 (1.6%) have had the complication since 1978, when the suture material used for anastomosis was changed from Tevdek polyester [Deknatel (Genzyme Biosurgery Corporation, Fall River, MA)] to Vicryl [Ethicon (Johnson & Johnson, Somerville, NJ)]. Before the change in suture material, 44 of 186 patients (23.6%) developed granulation tissue at the anastomosis. Thirty-eight of these 49 patients were managed by bronchoscopic removal of granulation tissue. Of 11 patients with more complicated problems, five required reoperation for a second resection and reconstruction; all had good results. Four patients required tracheostomy, one of which was temporary, and two patients were managed with T-tubes. Dehiscence and restenosis The most devastating complication following tracheal resection is dehiscence or restenosis. This occurred in 29 patients. If dehiscence is suspected, the patient must be taken immediately to the operating room for evaluation and stabilization of the airway. Seven patients with this complication died; two also had innominate artery erosion. Eight patients were managed with subsequent resection and reconstruction, all with either good (N = 6) or satisfactory (N = 2) results. Four patients required permanent tracheostomy. Five patients required a T-tube, three of
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which were temporary. Three patients had dehiscence of a small portion of the anastomosis. Two of these patients required re-exploration and primary closure, and one patient with a small leak was successfully managed with drainage of the cervical wound and antibiotics. Two patients required repeated dilatations. Laryngeal dysfunction A total of 25 patients had varying degrees of laryngeal dysfunction after the operation. Fourteen patients had minor or temporary dysfunction that prompted no specific treatment. Eleven patients had more severe dysfunction. Of these, seven patients required tracheostomy, four of which were temporary. One patient required a permanent T-tube, and another required a subglottic stent. Two patients required gastrostomy tube feedings for persistent aspiration resulting from glottic dysfunction. One death occurred in this group. Laryngeal complications, aspiration, or vocal cord dysfunction appeared in four of nine patients undergoing thyrohyoid laryngeal release (44%) and in eight of 40 patients (20%) undergoing suprahyoid release. Laryngotracheal resection (trachea – thyroid cartilage anastomosis) plus laryngeal release in eight patients led to three minor and four major complications in six of the eight patients. These complications included dysphagia, aspiration, malacia, and partial or complete dehiscence in three patients. Hemorrhage Five patients hemorrhaged from the innominate artery. Three of these patients died, two of whom had concomitant anastomotic separation. One patient was managed successfully with repair of the artery, and one was managed with division of the innominate artery. Anastomotic edema Four patients were noted to have swelling at their anastomoses. In one patient the swelling was minor and treatment consisted of oral steroids. Two patients were treated with temporary tracheostomy, and one patient was treated with a temporary T-tube. Infection Infectious complications developed in 34 patients. Wound infection accounted for 15 of these cases. Eight minor infections were treated with intravenous antibiotics and seven more extensive sternal infections required operative debridement. Nineteen patients had bronchitis or pneumonia, 14 of whom required intervention with bedside bronchoscopic treatment and antibiotics. Five more severe cases resulted in one death. Three patients were managed with temporary tracheostomy and two patients were managed with reintubation. Tracheomalacia Residual tracheomalacia was identified during or after the operation in 10 patients. There were two deaths in this group. Five patients required reopera-
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tion; four of these patients underwent a second resection and reconstruction and one patient underwent plastic ring splinting of the malacic segment. Results of the reoperations were good in two patients and satisfactory in two patients. The fifth patient required permanent tracheostomy. Two patients were treated with a T-tube, one of which was temporary. One patient required temporary tracheostomy. Other One postoperative myocardial infarction occurred, resulting in the patient’s death. Three patients with postoperative pneumothorax were treated chest tube thoracostomy. One of each of the following complications was seen: intravenous line infection, deep venous thrombosis, atrial fibrillation, insulin reaction, and aspiration through a T-tube, requiring conversion to tracheostomy.
Deaths Twelve perioperative deaths occurred in this compilation of patients. Complications related to anastomotic dehiscence were the most common causes, accounting for seven deaths. Only two patients were supported with ventilators at the time of resection, and three patients required postoperative reintubation for retained secretions. One patient had received mediastinal radiation therapy for Hodgkin’s disease with subsequent paratracheal fibrosis and failure of anastomotic healing despite omental wrapping. Two patients had a tracheoinnominate artery fistula after dehiscence. Two patients died of airway obstruction secondary to residual tracheomalacia. There was one postoperative fatal myocardial infarction. One patient died at home from respiratory failure of unknown cause. Experience plays a role in the incidence of complications (Table 2). In an earlier report, Grillo [4] noted a reduction in the number of deaths, failures of reconstruction, and number of complications in the second half of a personal series of 279 patients operated upon for postintubation stenosis. In contrast with the complications seen with resection and reconstruction for postintubation stenosis, Grillo and Mathisen [5] reported their results for treatment of primary tracheal neoplasms. The type and incidence of complications were slightly different than following resection for postintubation stenosis. Anastomotic stenosis developed in two patients who underwent tracheal resection, one of which had a transient air leak. Both patients later underwent re-resection successfully, one while receiving high-dose steroids. Stenoses developed in four patients after carinal Table 2 Influence of experience on management of postintubation lesions Case No.
Deaths Failures Complications
1 – 139
140 – 279
4 13 42
1 7 30
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resection. Two patients who had undergone pneumonectomy with carinal resection underwent re-resection successfully. Two other patients required upper lobectomy of the reimplanted right lung with reattachment of the bronchus intermedius or lower lobe. Both procedures were successful. Three air leaks were handled conservatively. In the era before absorbable sutures were used, four patients developed suture line granulomas, which were managed with bronchoscopic intervention. One esophageal fistula occurred after transthoracic tracheal resection with extensive full-thickness resection of the esophageal wall. One small fistula healed spontaneously. Vocal cord paralysis occurred in eight patients who underwent tracheal or carinal resection for squamous carcinoma and in three patients who underwent tracheal or carinal resection for adenoid cystic carcinoma. Six patients experienced aspiration on swallowing, principally after laryngeal release prompted by extended resection. Most occurrences of vocal cord paralysis resolved with time; however, temporary gastrostomy was infrequently required. One patient had a small empyema after transthoracic tracheal resection that was ultimately treated with drainage. In two patients, pulmonary edema developed acutely after carinal resection with right pneumonectomy. Three other patients had pneumonia. One patient developed hypoxemia after a carinal resection with anastomosis of the trachea to the right mainstem bronchus and exclusion of the left lung. The left pulmonary artery had not been ligated. This patient ultimately required a left pneumonectomy to remove the nonfunctioning but shunting lung.
Treatment and prevention of complications Granulation tissue Granulation tissue at the suture line results predominately from nonabsorbable sutures. The granulation tissue should be removed and the offending suture extracted with biopsy forceps. Triamcinolone can be injected locally to impede the reformation of granulations. Adoption of absorbable sutures for anastomosis (4-0 Vicryl) has virtually eliminated anastomotic granulations and some late restenosis. Airway separation Acute airway separation post tracheal reconstruction might first manifest as subcutaneous emphysema. This finding demands bronchoscopy emergently and re-exploration to identify tracheal dehiscence. Limited anastomotic separation might be resutured if it occurs early and there is no necrosis from compromised blood supply. The repair should then be buttressed with a well-vascularized cervical muscle flap. If the tissues do not appear to be appropriate for resuturing, a tracheostomy tube can be placed across the defect to be replaced later by a silicone T-tube [7]. A T-tube can be placed initially if the patient does not require a sealed airway.
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With partial restenosis, the resulting airway might be clinically tolerated and sometimes might improve with endoscopic techniques, including laser. Severe stenosis or recurring partial stenosis requires aggressive treatment because other measures offer only temporary palliation. The stenotic area can be dilated and a T-tube can be placed across it to temporize it. After an attempt at tracheal reconstruction has failed, 4 to 6 months should be allowed to quell the inflammation before another resection is undertaken. The presence of a T-tube permits the luxury of waiting while maintaining an adequate airway. The difficulties of tracheal reconstruction increase markedly with each attempt at repair. Stenosis Ensuring a tension-free reconstruction can prevent stenosis of a tracheal anastomosis. Furthermore, when proceeding with tracheal resection for postintubation stenosis, all of the trachea that is involved by severe inflammatory stenosis must be removed to prevent recurrence at that site. On the other hand, it is important not to resect so much trachea that there will be excessive tension at the anastomosis, particularly in patients with tumors or with previously operated stenotic lesions. Anastomotic tension is usually judged clinically. Adjunctive maneuvers such as laryngeal and hilar release might be required. On occasion, it is better to abort the operation after exploration of a trachea rather than perform too lengthy a resection. Conservative management of postintubation lesions can be accomplished with inlying silicone rubber T-tubes, and obstructions from a tumor can be opened bronchoscopically and palliated with radiation. Hemorrhage Major hemorrhage, which is usually from the innominate artery, mandates immediate reoperation. If blood enters the airway, emergent placement of a cuffed endotracheal tube can potentially seal the bleeding site while operative plans are set in motion. The surgical approach is through a combination of collar incision and median sternotomy. The innominate artery is controlled proximally and distally and the fistulous segment is resected. Proximal and distal ends of the artery are then closed with two layers of running vascular suture and the divided ends are covered in healthy tissue such as thymus, omentum, or cervical muscle. Simple ligation is not advised. If available, intraoperative electroencephalogram monitoring can be used while the artery is clamped. If marked changes occur on the electroencephalogram, an autologous saphenous vein graft should be used with omentum generously wrapped around it to deal with local infection. Neurologic sequelae are rare after division of the innominate artery in the presence of a previously normal circulation. Dissection behind the innominate artery should be performed on the trachea to leave adjacent tissue undisturbed around the artery. This will prevent most—if not all—postoperative hemorrhages from that artery. In reoperations, dense adherence might be encountered between the innominate artery and the trachea. In such
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cases, healthy tissue such as pedicled cervical strap muscle can be interposed between the trachea and the artery. Similarly, in the thorax, tissue must always be interposed between the tracheobronchial suture lines and the pulmonary artery. Malacia Residual malacia is best treated by recognizing it during the original operation and including it in the resection. If doing so would extend the resection excessively, the trachea can be splinted either internally with a T-tube without resection, or externally with plastic rings. Foreign material is avoided unless it is absolutely necessary. Laryngeal release can potentially enable the length of resection to be increased, permitting excision of adjacent malacia along with a stenosis. Fistulae Tracheoesophageal fistulae are rare complications of tracheal resection and reconstruction. They should be repaired if encountered. If there are technical or systemic reasons to delay repair, the fistula can usually be managed with a tracheal T-tube or, sometimes, a cuffed tracheostomy tube. Gastrostomy is implemented to avoid aspiration from reflux and jejunostomy for nutrition. The fistula is repaired when local inflammation has subsided [8]. Repair can be accomplished by simple division and closure of the fistula or by segmental tracheal resection and primary anastomosis with esophageal closure. Diversion of the esophageal contents from the tracheobronchial tree is rarely indicated. Aspiration Aspiration on deglutition is commonly seen early after thyrohyoid release of the larynx and, less often, after suprahyoid release. The glottis might close inadequately on swallowing when the trachea has been markedly shortened, when there has been injury to one of the recurrent nerves, or when neurologic injury is present. If there is no improvement after a prolonged period during which the patient has been fed by gastrostomy, it might become necessary to surgically close the glottis and resort to tracheostomy and an artificial speech device. Glottic problems Glottic problems, including an inadequate aperture or inadequate closure that permits aspiration, must be corrected before tracheal reconstruction is attempted. Careful radiologic and endoscopic assessment of the state and function of the glottis and subglottic area should therefore be ascertained preoperatively [9]. Of equal importance is the evaluation of the presence or absence of malacia in addition to a stenotic lesion and any disorders of deglutition. Consultation with a specialized radiologist, otolaryngologist, pulmonary specialist, and anesthesiologist will avoid many complications that can lead to postoperative disasters.
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Patients should be selected, prepared, and managed intraoperatively in such a fashion that they will rarely require postoperative intubation and ventilation. Vocal cord paralysis Vocal cord paralysis usually warrants a period of observation before any intervention is undertaken. Over a period of 6 months to 1 year, the patient’s voice might return. If not, otolaryngologic procedures including teflon injection of the paralyzed cord can improve the situation. If obstruction results from bilateral vocal cord paralysis, the patient requires urgent endotracheal intubation, tracheostomy, or a T-tube through the vocal cords. Procedures such as arytenoidectomy or cord lateralization are then needed to provide an adequate glottic aperture. Edema Acute airway edema after tracheal reconstruction is immediately treated with racemic epinephrine, head elevation, diuretics, and 24 hours of systemically administered steroids. Local steroid injection has also been used concomitantly. An uncuffed endotracheal tube might be required for 48 to 72 hours, followed by detection of an endotracheal air leak. If edema persists beyond this period, a small tracheostomy tube can be carefully placed away from the anastomotic suture line and distant from the innominate artery. A tracheostomy tube is never placed through a fresh anastomosis or so close as to infringe upon the healing of an anastomosis. Edema is most likely to develop after a complex laryngotracheal resection for subglottic stenosis involving the larynx. Another potential therapy for acute airway edema after tracheal reconstruction is the use of Heliox [10,11]. Helium has a density that is significantly lower than that of air. A mixture of helium and oxygen, termed Heliox, has a lower density than does a mixture of nitrogen and oxygen. Breathing Heliox leads to a reduction in resistance to flow within the airways, and consequently to a decrease in the work of breathing. These beneficial effects have been observed in patients with asthma, chronic obstructive lung disease, bronchiolitis, bronchopulmonary dysplasia, and upper airways obstruction [12]. The gas mixture might provide the time necessary while awaiting the benefit of conservative maneuvers previously mentioned. Stoma A persistent stoma usually results when the stoma has been present for a long time and has eroded to a large size. The cutaneous epithelium has usually become adherent to the tracheal epithelium. Such stomas are often closed during the initial tracheal reconstruction or closed secondarily at another setting. Surgical resection for postintubation stenosis is almost never an emergency. Only in patients with stenosis immediately above the carina (where airway control is exceedingly difficult to maintain) or in the patient with hemorrhage from tracheoinnominate fistula is emergent surgical intervention required. In almost all other patients it is possible to dilate the stenosis endoscopically or through a
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Table 3 Postintubation lesions: results of treatment complications
Granulations Separation Restenosis Malacia Hemorrhage Tracheoesophageal fistula Cord dysfunction Aspiration Wound infection Edema
No.
Good
Satisfactory
Failed
Death
28 4 21 3 2 1 5 1 6 1
24 – 6 1 1 – – – 6 –
4 2 15 – – – 4 – – –
– – – 1 – – 1 1 – 1
– 2 – 1 1 1 – – – –
tracheostomy. If necessary, one could intubate across the lesion with a tracheostomy tube or T-tube [13]. Long-armed T-tubes are available for low stenoses. Patients on ventilators should almost never be subjected to tracheal reconstruction. Table 3 summarizes the results of management of complications after resection of postintubation lesions [5]. Separation, hemorrhage, and tracheoesophageal fistula, although infrequently encountered, were the most dangerous, resulting in four of the five deaths.
Summary Basic principles of tracheal reconstruction, which were introduced in the 1960s and 1970s, served to reduce the prevalence of many complications. These principles include thorough preoperative assessment (endoscopic and radiologic) of the tracheal anatomy and glottic function, avoidance of excessive anastomotic tension, preservation of tracheal blood supply, and meticulous dissection and anastomosis. The tracheal surgeon should have access to expert help in radiology and anesthesiology, experienced nursing units, and the help and advice of consultants, especially otolaryngologists. The surgical approach should be meticulously planned. No irreversible maneuvers should be performed until one establishes certainty to proceed to resection. The surgeon should not attempt to exceed the limits of what appears to be reasonably possible. It must be remembered that a permanent tracheal T-tube might be the best solution for a patient with extensive tracheal damage that would defy reconstruction.
References [1] Andrews MJ, Pearson FG. Incidence and pathogenesis of tracheal injury following cuffed tube tracheostomy with assisted ventilation. Ann Surg 1971;173:249 – 63. [2] Cooper JD, Grillo HC. The evolution of tracheal injury due to ventilatory assistance through cuffed tubes: a pathologic study. Ann Surg 1969;169:334 – 48. [3] Wilson RS. Anesthetic management for tracheal reconstruction. In: Grillo HC, Eschapasse H,
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[12]
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editors. International Trends in General Thoracic Surgery, Vol 2. Philadelphia: WB Saunders; 1987. p. 1 – 18. Grillo HC, Zannini P, Michelassi F. Complications of tracheal reconstruction: Incidence, treatment and prevention. J Thorac Cardiovasc Surg 1986;91:322 – 8. Grillo HC, Mathisen DJ. Primary tracheal tumors: Treatment and results. Ann Thorac Surg 1990; 49:69 – 77. Grillo HC, Donahue DM, Mathisen DJ, et al. Post intubation tracheal stenosis. Treatment and results. J Thorac Cardiovasc Surg 1995;109:486 – 93. Montgomery WW. Suprahyoid release for tracheal stenosis. Arch Otolaryngol 1974;99:255 – 60. Mathisen DJ, Grillo HC, Wain JC, et al. Management of acquired nonmalignant tracheoesophageal fistula. Ann Thorac Surg 1991;52:759 – 65. Momose KJ, MacMillan Jr AS. Roentgenologic investigations of the larynx and trachea. Radiol Clin North Am 1978;16:321 – 41. Chevrolet J. Helium oxygen mixtures in the intensive care unit. Critical Care 2001;5:179 – 81. Ho AM, Dion PW, Karmakar MK, et al. Use of heliox in critical upper airway obstruction: physical and physiologic considerations in choosing the optimal helium: oxygen mix. Resuscitation 2002;52:297 – 300. Jolliet P, Tassaux D, Chevrolet J. Beneficial effects of helium-oxygen mixtures in acute respiratory failure. In: Yearbook of Intensive Care and Emergency Medicine. Berlin: Springer Verlag; 1999. p. 244 – 51. Gaissert H, Grillo HC, Mathisen DJ, et al. Temporary and permanent restoration of airway continuity with the tracheal T-tube. J Thorac Cardiovasc Surg 1994;107:600 – 6.
Management of complications of tracheal surgery Michael Lanuti, MDa,b,*, Douglas J. Mathisen, MDa,b a
Massachusetts General Hospital, Blake 1570, 55 Fruit Street, Boston, MA 02114, USA b Harvard Medical School, 25 Shattuck Street, Boston, MA 02115, USA
Post-intubation tracheal injuries remain the most common indication for tracheal resection and reconstruction [1,2]. Meticulous attention to the details of intubation, the technique of tracheostomy, and postoperative care can avoid the development of complications of tracheal stenosis. Injury to the tracheal mucosa during intubation might predispose patients to the development of stenosis. Proper selection of tube sizes is essential for the prevention of laryngeal injury and injury to the subglottic area. Ischemic injury to the mucosa or the larynx or subglottis from overly large endotracheal tubes occurs more commonly in women, who tend to have smaller larynxes than men. Despite low-pressure tracheostomy cuffs, overinflation of endotracheal and tracheostomy cuffs might lead to injury and tracheal stenosis. Overinflation of low-pressure cuffs is responsible for a large number of tracheal stenoses. It is important to avoid excessive tension on tracheostomy tubes; excessive tension leads to excessive destruction of tracheal cartilages, increasing the likelihood of a stomal stenosis after removal of the tracheostomy tube. If another tracheotomy is needed to control the airway, it is imperative that the tracheostomy be placed through the most damaged portion of the trachea, thus preserving as much viable trachea as possible for future reconstruction.
High-risk patients There are certain circumstances that place patients at high risk for complications following tracheal resection and reconstruction. One of the most critical factors influencing the success of tracheal surgery is the absence of need for mechanical ventilation. The need for mechanical ventilation must be considered in high-risk
* Corresponding author. Michael Lanuti, MD, Massachusetts General Hospital, Blake 1570, 55 Fruit Street, Boston, MA 02114. E-mail address: [email protected] (M. Lanuti). 1052-3359/03/$ – see front matter D 2003, Elsevier Inc. All rights reserved. doi:10.1016/S1052-3359(03)00007-3
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groups such as quadriplegics and those affected by neuromuscular disorders associated with weakness. Mechanical ventilation following tracheal resection increases the risk of anastomotic complications and the possibility of dehiscence. Many patients are mistakenly treated with high-dose steroids for presumed adult-onset asthma. It is the authors’ belief that systemic steroids and some degree of anastomotic tension are associated with a greater risk of anastomotic dehiscence. It is therefore mandatory that patients be weaned from steroids before any surgical intervention. It is often necessary to dilate strictures or remove tumor bronchoscopically while steroids are being weaned. Prior radiation therapy ( > 5000 cGy completed over 12 months before planned resection) is also a relative contraindication. In certain highly selected patients, tracheal resection and reconstruction can be performed using a well-vascularized pedicle (eg, omentum) to encircle and buttress the anastomosis. Another important variable in tracheal resection is the condition of the tracheal mucosa. It is imperative that the tracheal mucosa be assessed. The presence of inflammation related to the underlying disease or recent surgical procedure (ie, tracheostomy, trauma, and laser) might dictate postponement of reconstruction until the process has subsided. Before reconstruction, a careful assessment of the glottis should be obtained to ensure an adequate glottic airway. It has been the authors’ practice to correct any glottic abnormalities before tracheal reconstruction. Postintubation injuries must be evaluated for tracheomalacia by way of awake flexible bronchoscopy or fluoroscopy. Malacia might be observed either proximal or distal to an area of stenosis, and it greatly influences the amount of trachea that is suitable for reconstruction. Patients with known Wegener’s granulomatosis and relapsing polychondritis are extremely unpredictable and are best treated with palliative measures rather than reconstruction.
Airway management Management of critical airway stenosis can be a formidable challenge. Understanding the principles of management might avoid ill-advised surgery and minimize potential complications. Emergency tracheal resection should be avoided. It is always preferable to stabilize the airway, properly evaluate the patient, and perform resection under ideal circumstances. Upon initial presentation, simple measures such as cool humidified mist, bed rest, head elevation, and cautious sedation are often helpful. As a substitute for oxygen, Heliox (BOC Gases, Murray Hill, NJ) is often helpful in the acute setting. The lower viscosity of Heliox is a great advantage in a stenotic airway. Any airway manipulation under local anesthesia—especially in the outpatient setting—could precipitate airway obstruction from secretions, hemorrhage, or swelling. If intervention is necessary, postintubation stenosis can be safely dilated under general anesthesia using dilators and rigid and flexible bronchoscopes [3]. The procedure is performed under direct visualization starting with a number 3.5 or 4 mm
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pediatric rigid bronchoscope, gradually increasing the size until a 7 or 8 mm adult rigid bronchoscope can be gently passed through the stenosis. Tumors can be cored out with biopsy forceps, rigid bronchoscopes, or with a laser. Intervention in this manner can stabilize the airway from a few days to weeks to allow further evaluation of a patient’s airway. Acute airway distress can develop following tracheal resection and reconstruction in some patients. The etiology of this distress might be glottic edema, inadequate airway following reconstruction, unrecognized glottic problems, malacia, or vocal cord paralysis. If the need for an airway is anticipated at the time of surgery, an uncuffed tracheostomy tube (#4 or #5) can be placed two rings below the tracheal anastomosis with proper coverage of the suture line with local tissues (eg, thyroid or cervical strap muscle). Alternatively, a small, uncuffed endotracheal tube can be left in place and removed 2 to 3 days later in the operating room with the patient under a light general anesthetic. If an inadequate airway still exists, a small tracheostomy tube can be placed at that time. Postoperative edema might compromise the airway. Edema of the larynx after tracheal reconstruction is initially treated with fluid restriction, racemic epinephrine, and a brief course of systemic steroids (24 –36 hours). If this treatment does not resolve the problem, it is best to intubate the patient over a small, uncuffed endotracheal tube. A brief period of time should be allowed for swelling to subside, then the patient should be evaluated in the operating room for intubation or tracheostomy as described previously.
Management of complications Complications of tracheal resection and reconstruction vary with the pathologic condition. As previously stated, the vast majority of operations are performed for postintubation stenosis. Resection of tracheal neoplasms is the next most common reconstruction performed. Reconstructions for infectious diseases, idiopathic stenosis, traumatic lesions, congenital deformities, and extrinsic compression present with special problems, but the general principles are the same. For tumors, the tracheal mucosa is usually normal, whereas for postintubation problems, the mucosa can have varying degrees of inflammation or fibrosis. The most comprehensive account of complications following tracheal resection was reported by Grillo and colleagues in 1986 [4], and updated in 1990 for resection of neoplasms [5] and for resection of postintubation stenosis in 1995 [6]. The results of this work form the basis of further discussions about complications of tracheal resection.
Results A total of 521 tracheal resections and reconstructions were performed on 503 patients. Thirteen patients had restenosis after an initial procedure and were
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reoperated at a later date. Five patients had immediate failure because of residual tracheal malacia and were reoperated within hours of their initial procedure. Evaluation of this cumulative patient series revealed a progressive increase in the complication rate as the anastomotic level ascended. The failure rates were 2.2% for trachea – trachea anastomosis, 6.0% for a trachea –cricoid anastomosis, and 8.1% for trachea –thyroid anastomosis (Fig. 1). Minor complications became more prevalent with each level, from 16% to 17.1% to 21%, respectively. The major complication rate did not appear to change (13.9%, 15.4%, and 12.9%, respectively). Complications can be divided into failures of incomplete diagnosis, failure of technique, and those not easily classified. Failures of incomplete diagnosis, which were limited largely to postintubation lesions, resulted from (1) failure to recognize incompetence of the glottis before tracheal repair, and (2) failure to recognize the extent of malacia present in addition to stenosis, a condition that requires intervention at the initial operation. A third problem identified in patients after prior operative failure was that the extent of stenosis had been unrecognized with an inadequate resection. The second group of complications contains failure of technique. Formation of granulation tissue at the anastomosis must be classified as an error in technique and in selection of patients. Separation of an anastomosis is (in most cases) because of excessive tension caused by resection of too much trachea or failure to perform relaxing maneuvers to lessen tension. Excessive circumferential dissection of the trachea, particularly distal to the point of division, might compromise the blood supply and result in separation or stenosis. Excessive resection is more likely to occur in the management of tumors. Partial or complete stenosis can occur at the anastomotic line. This phenomenon results from granulation tissue that gradually turns into cicatrizing circumferential scar or, more often, into partial separation. The latter can occur without clinical air leak because of tension
Fig. 1. Categories of reconstruction. (a) Trachea to trachea anastomosis after segmental tracheal resection. (b) Cricotracheal anastomosis where transaction is just below the cricoid cartilage, or where a portion of lower cricoid cartilage, usually anterior, has been resected. (c) Anastomosis of tailored trachea to thyroid cartilage or cricothyroid membrane anteriorly, where subglottic laryngeal involvement by stenosis required laryngoplasty.
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Table 1 Complications of operations for postintubation tracheal stenosis
Granulations (Before 1978) (After 1978) Dehiscence Laryngeal dysfunction Malacia Hemorrhage Edema (anastomotic) Infection Wound Pulmonary Myocardial infarction TEF Pneumothorax Line infection Atrial fibrillation Deep venous thrombosis Total
Major
Minor
Total
11 10 1 28 11 10 5 3
38 34 4 1 14 0 0 1
49 44 5 29 25 10 5 4
7 5 1 1 0 0 0 0 82
8 14 0 0 3 1 1 1 82
15 19 1 1 3 1 1 1 164
Data from Grillo HC, Donahue DM, Mathisen DJ, et al. Postintubation tracheal stenosis: treatment and results. J Thorac Cardiovasc Surg 1995;109:486 – 93.
over time. Complications following resection for postintubation stenosis are summarized in Table 1. Granulations In 49 patients, granulation tissue formed at the site of the tracheal anastomosis. Only five such cases out of 317 (1.6%) have had the complication since 1978, when the suture material used for anastomosis was changed from Tevdek polyester [Deknatel (Genzyme Biosurgery Corporation, Fall River, MA)] to Vicryl [Ethicon (Johnson & Johnson, Somerville, NJ)]. Before the change in suture material, 44 of 186 patients (23.6%) developed granulation tissue at the anastomosis. Thirty-eight of these 49 patients were managed by bronchoscopic removal of granulation tissue. Of 11 patients with more complicated problems, five required reoperation for a second resection and reconstruction; all had good results. Four patients required tracheostomy, one of which was temporary, and two patients were managed with T-tubes. Dehiscence and restenosis The most devastating complication following tracheal resection is dehiscence or restenosis. This occurred in 29 patients. If dehiscence is suspected, the patient must be taken immediately to the operating room for evaluation and stabilization of the airway. Seven patients with this complication died; two also had innominate artery erosion. Eight patients were managed with subsequent resection and reconstruction, all with either good (N = 6) or satisfactory (N = 2) results. Four patients required permanent tracheostomy. Five patients required a T-tube, three of
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which were temporary. Three patients had dehiscence of a small portion of the anastomosis. Two of these patients required re-exploration and primary closure, and one patient with a small leak was successfully managed with drainage of the cervical wound and antibiotics. Two patients required repeated dilatations. Laryngeal dysfunction A total of 25 patients had varying degrees of laryngeal dysfunction after the operation. Fourteen patients had minor or temporary dysfunction that prompted no specific treatment. Eleven patients had more severe dysfunction. Of these, seven patients required tracheostomy, four of which were temporary. One patient required a permanent T-tube, and another required a subglottic stent. Two patients required gastrostomy tube feedings for persistent aspiration resulting from glottic dysfunction. One death occurred in this group. Laryngeal complications, aspiration, or vocal cord dysfunction appeared in four of nine patients undergoing thyrohyoid laryngeal release (44%) and in eight of 40 patients (20%) undergoing suprahyoid release. Laryngotracheal resection (trachea – thyroid cartilage anastomosis) plus laryngeal release in eight patients led to three minor and four major complications in six of the eight patients. These complications included dysphagia, aspiration, malacia, and partial or complete dehiscence in three patients. Hemorrhage Five patients hemorrhaged from the innominate artery. Three of these patients died, two of whom had concomitant anastomotic separation. One patient was managed successfully with repair of the artery, and one was managed with division of the innominate artery. Anastomotic edema Four patients were noted to have swelling at their anastomoses. In one patient the swelling was minor and treatment consisted of oral steroids. Two patients were treated with temporary tracheostomy, and one patient was treated with a temporary T-tube. Infection Infectious complications developed in 34 patients. Wound infection accounted for 15 of these cases. Eight minor infections were treated with intravenous antibiotics and seven more extensive sternal infections required operative debridement. Nineteen patients had bronchitis or pneumonia, 14 of whom required intervention with bedside bronchoscopic treatment and antibiotics. Five more severe cases resulted in one death. Three patients were managed with temporary tracheostomy and two patients were managed with reintubation. Tracheomalacia Residual tracheomalacia was identified during or after the operation in 10 patients. There were two deaths in this group. Five patients required reopera-
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tion; four of these patients underwent a second resection and reconstruction and one patient underwent plastic ring splinting of the malacic segment. Results of the reoperations were good in two patients and satisfactory in two patients. The fifth patient required permanent tracheostomy. Two patients were treated with a T-tube, one of which was temporary. One patient required temporary tracheostomy. Other One postoperative myocardial infarction occurred, resulting in the patient’s death. Three patients with postoperative pneumothorax were treated chest tube thoracostomy. One of each of the following complications was seen: intravenous line infection, deep venous thrombosis, atrial fibrillation, insulin reaction, and aspiration through a T-tube, requiring conversion to tracheostomy.
Deaths Twelve perioperative deaths occurred in this compilation of patients. Complications related to anastomotic dehiscence were the most common causes, accounting for seven deaths. Only two patients were supported with ventilators at the time of resection, and three patients required postoperative reintubation for retained secretions. One patient had received mediastinal radiation therapy for Hodgkin’s disease with subsequent paratracheal fibrosis and failure of anastomotic healing despite omental wrapping. Two patients had a tracheoinnominate artery fistula after dehiscence. Two patients died of airway obstruction secondary to residual tracheomalacia. There was one postoperative fatal myocardial infarction. One patient died at home from respiratory failure of unknown cause. Experience plays a role in the incidence of complications (Table 2). In an earlier report, Grillo [4] noted a reduction in the number of deaths, failures of reconstruction, and number of complications in the second half of a personal series of 279 patients operated upon for postintubation stenosis. In contrast with the complications seen with resection and reconstruction for postintubation stenosis, Grillo and Mathisen [5] reported their results for treatment of primary tracheal neoplasms. The type and incidence of complications were slightly different than following resection for postintubation stenosis. Anastomotic stenosis developed in two patients who underwent tracheal resection, one of which had a transient air leak. Both patients later underwent re-resection successfully, one while receiving high-dose steroids. Stenoses developed in four patients after carinal Table 2 Influence of experience on management of postintubation lesions Case No.
Deaths Failures Complications
1 – 139
140 – 279
4 13 42
1 7 30
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resection. Two patients who had undergone pneumonectomy with carinal resection underwent re-resection successfully. Two other patients required upper lobectomy of the reimplanted right lung with reattachment of the bronchus intermedius or lower lobe. Both procedures were successful. Three air leaks were handled conservatively. In the era before absorbable sutures were used, four patients developed suture line granulomas, which were managed with bronchoscopic intervention. One esophageal fistula occurred after transthoracic tracheal resection with extensive full-thickness resection of the esophageal wall. One small fistula healed spontaneously. Vocal cord paralysis occurred in eight patients who underwent tracheal or carinal resection for squamous carcinoma and in three patients who underwent tracheal or carinal resection for adenoid cystic carcinoma. Six patients experienced aspiration on swallowing, principally after laryngeal release prompted by extended resection. Most occurrences of vocal cord paralysis resolved with time; however, temporary gastrostomy was infrequently required. One patient had a small empyema after transthoracic tracheal resection that was ultimately treated with drainage. In two patients, pulmonary edema developed acutely after carinal resection with right pneumonectomy. Three other patients had pneumonia. One patient developed hypoxemia after a carinal resection with anastomosis of the trachea to the right mainstem bronchus and exclusion of the left lung. The left pulmonary artery had not been ligated. This patient ultimately required a left pneumonectomy to remove the nonfunctioning but shunting lung.
Treatment and prevention of complications Granulation tissue Granulation tissue at the suture line results predominately from nonabsorbable sutures. The granulation tissue should be removed and the offending suture extracted with biopsy forceps. Triamcinolone can be injected locally to impede the reformation of granulations. Adoption of absorbable sutures for anastomosis (4-0 Vicryl) has virtually eliminated anastomotic granulations and some late restenosis. Airway separation Acute airway separation post tracheal reconstruction might first manifest as subcutaneous emphysema. This finding demands bronchoscopy emergently and re-exploration to identify tracheal dehiscence. Limited anastomotic separation might be resutured if it occurs early and there is no necrosis from compromised blood supply. The repair should then be buttressed with a well-vascularized cervical muscle flap. If the tissues do not appear to be appropriate for resuturing, a tracheostomy tube can be placed across the defect to be replaced later by a silicone T-tube [7]. A T-tube can be placed initially if the patient does not require a sealed airway.
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With partial restenosis, the resulting airway might be clinically tolerated and sometimes might improve with endoscopic techniques, including laser. Severe stenosis or recurring partial stenosis requires aggressive treatment because other measures offer only temporary palliation. The stenotic area can be dilated and a T-tube can be placed across it to temporize it. After an attempt at tracheal reconstruction has failed, 4 to 6 months should be allowed to quell the inflammation before another resection is undertaken. The presence of a T-tube permits the luxury of waiting while maintaining an adequate airway. The difficulties of tracheal reconstruction increase markedly with each attempt at repair. Stenosis Ensuring a tension-free reconstruction can prevent stenosis of a tracheal anastomosis. Furthermore, when proceeding with tracheal resection for postintubation stenosis, all of the trachea that is involved by severe inflammatory stenosis must be removed to prevent recurrence at that site. On the other hand, it is important not to resect so much trachea that there will be excessive tension at the anastomosis, particularly in patients with tumors or with previously operated stenotic lesions. Anastomotic tension is usually judged clinically. Adjunctive maneuvers such as laryngeal and hilar release might be required. On occasion, it is better to abort the operation after exploration of a trachea rather than perform too lengthy a resection. Conservative management of postintubation lesions can be accomplished with inlying silicone rubber T-tubes, and obstructions from a tumor can be opened bronchoscopically and palliated with radiation. Hemorrhage Major hemorrhage, which is usually from the innominate artery, mandates immediate reoperation. If blood enters the airway, emergent placement of a cuffed endotracheal tube can potentially seal the bleeding site while operative plans are set in motion. The surgical approach is through a combination of collar incision and median sternotomy. The innominate artery is controlled proximally and distally and the fistulous segment is resected. Proximal and distal ends of the artery are then closed with two layers of running vascular suture and the divided ends are covered in healthy tissue such as thymus, omentum, or cervical muscle. Simple ligation is not advised. If available, intraoperative electroencephalogram monitoring can be used while the artery is clamped. If marked changes occur on the electroencephalogram, an autologous saphenous vein graft should be used with omentum generously wrapped around it to deal with local infection. Neurologic sequelae are rare after division of the innominate artery in the presence of a previously normal circulation. Dissection behind the innominate artery should be performed on the trachea to leave adjacent tissue undisturbed around the artery. This will prevent most—if not all—postoperative hemorrhages from that artery. In reoperations, dense adherence might be encountered between the innominate artery and the trachea. In such
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cases, healthy tissue such as pedicled cervical strap muscle can be interposed between the trachea and the artery. Similarly, in the thorax, tissue must always be interposed between the tracheobronchial suture lines and the pulmonary artery. Malacia Residual malacia is best treated by recognizing it during the original operation and including it in the resection. If doing so would extend the resection excessively, the trachea can be splinted either internally with a T-tube without resection, or externally with plastic rings. Foreign material is avoided unless it is absolutely necessary. Laryngeal release can potentially enable the length of resection to be increased, permitting excision of adjacent malacia along with a stenosis. Fistulae Tracheoesophageal fistulae are rare complications of tracheal resection and reconstruction. They should be repaired if encountered. If there are technical or systemic reasons to delay repair, the fistula can usually be managed with a tracheal T-tube or, sometimes, a cuffed tracheostomy tube. Gastrostomy is implemented to avoid aspiration from reflux and jejunostomy for nutrition. The fistula is repaired when local inflammation has subsided [8]. Repair can be accomplished by simple division and closure of the fistula or by segmental tracheal resection and primary anastomosis with esophageal closure. Diversion of the esophageal contents from the tracheobronchial tree is rarely indicated. Aspiration Aspiration on deglutition is commonly seen early after thyrohyoid release of the larynx and, less often, after suprahyoid release. The glottis might close inadequately on swallowing when the trachea has been markedly shortened, when there has been injury to one of the recurrent nerves, or when neurologic injury is present. If there is no improvement after a prolonged period during which the patient has been fed by gastrostomy, it might become necessary to surgically close the glottis and resort to tracheostomy and an artificial speech device. Glottic problems Glottic problems, including an inadequate aperture or inadequate closure that permits aspiration, must be corrected before tracheal reconstruction is attempted. Careful radiologic and endoscopic assessment of the state and function of the glottis and subglottic area should therefore be ascertained preoperatively [9]. Of equal importance is the evaluation of the presence or absence of malacia in addition to a stenotic lesion and any disorders of deglutition. Consultation with a specialized radiologist, otolaryngologist, pulmonary specialist, and anesthesiologist will avoid many complications that can lead to postoperative disasters.
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Patients should be selected, prepared, and managed intraoperatively in such a fashion that they will rarely require postoperative intubation and ventilation. Vocal cord paralysis Vocal cord paralysis usually warrants a period of observation before any intervention is undertaken. Over a period of 6 months to 1 year, the patient’s voice might return. If not, otolaryngologic procedures including teflon injection of the paralyzed cord can improve the situation. If obstruction results from bilateral vocal cord paralysis, the patient requires urgent endotracheal intubation, tracheostomy, or a T-tube through the vocal cords. Procedures such as arytenoidectomy or cord lateralization are then needed to provide an adequate glottic aperture. Edema Acute airway edema after tracheal reconstruction is immediately treated with racemic epinephrine, head elevation, diuretics, and 24 hours of systemically administered steroids. Local steroid injection has also been used concomitantly. An uncuffed endotracheal tube might be required for 48 to 72 hours, followed by detection of an endotracheal air leak. If edema persists beyond this period, a small tracheostomy tube can be carefully placed away from the anastomotic suture line and distant from the innominate artery. A tracheostomy tube is never placed through a fresh anastomosis or so close as to infringe upon the healing of an anastomosis. Edema is most likely to develop after a complex laryngotracheal resection for subglottic stenosis involving the larynx. Another potential therapy for acute airway edema after tracheal reconstruction is the use of Heliox [10,11]. Helium has a density that is significantly lower than that of air. A mixture of helium and oxygen, termed Heliox, has a lower density than does a mixture of nitrogen and oxygen. Breathing Heliox leads to a reduction in resistance to flow within the airways, and consequently to a decrease in the work of breathing. These beneficial effects have been observed in patients with asthma, chronic obstructive lung disease, bronchiolitis, bronchopulmonary dysplasia, and upper airways obstruction [12]. The gas mixture might provide the time necessary while awaiting the benefit of conservative maneuvers previously mentioned. Stoma A persistent stoma usually results when the stoma has been present for a long time and has eroded to a large size. The cutaneous epithelium has usually become adherent to the tracheal epithelium. Such stomas are often closed during the initial tracheal reconstruction or closed secondarily at another setting. Surgical resection for postintubation stenosis is almost never an emergency. Only in patients with stenosis immediately above the carina (where airway control is exceedingly difficult to maintain) or in the patient with hemorrhage from tracheoinnominate fistula is emergent surgical intervention required. In almost all other patients it is possible to dilate the stenosis endoscopically or through a
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Table 3 Postintubation lesions: results of treatment complications
Granulations Separation Restenosis Malacia Hemorrhage Tracheoesophageal fistula Cord dysfunction Aspiration Wound infection Edema
No.
Good
Satisfactory
Failed
Death
28 4 21 3 2 1 5 1 6 1
24 – 6 1 1 – – – 6 –
4 2 15 – – – 4 – – –
– – – 1 – – 1 1 – 1
– 2 – 1 1 1 – – – –
tracheostomy. If necessary, one could intubate across the lesion with a tracheostomy tube or T-tube [13]. Long-armed T-tubes are available for low stenoses. Patients on ventilators should almost never be subjected to tracheal reconstruction. Table 3 summarizes the results of management of complications after resection of postintubation lesions [5]. Separation, hemorrhage, and tracheoesophageal fistula, although infrequently encountered, were the most dangerous, resulting in four of the five deaths.
Summary Basic principles of tracheal reconstruction, which were introduced in the 1960s and 1970s, served to reduce the prevalence of many complications. These principles include thorough preoperative assessment (endoscopic and radiologic) of the tracheal anatomy and glottic function, avoidance of excessive anastomotic tension, preservation of tracheal blood supply, and meticulous dissection and anastomosis. The tracheal surgeon should have access to expert help in radiology and anesthesiology, experienced nursing units, and the help and advice of consultants, especially otolaryngologists. The surgical approach should be meticulously planned. No irreversible maneuvers should be performed until one establishes certainty to proceed to resection. The surgeon should not attempt to exceed the limits of what appears to be reasonably possible. It must be remembered that a permanent tracheal T-tube might be the best solution for a patient with extensive tracheal damage that would defy reconstruction.
References [1] Andrews MJ, Pearson FG. Incidence and pathogenesis of tracheal injury following cuffed tube tracheostomy with assisted ventilation. Ann Surg 1971;173:249 – 63. [2] Cooper JD, Grillo HC. The evolution of tracheal injury due to ventilatory assistance through cuffed tubes: a pathologic study. Ann Surg 1969;169:334 – 48. [3] Wilson RS. Anesthetic management for tracheal reconstruction. In: Grillo HC, Eschapasse H,
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[12]
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editors. International Trends in General Thoracic Surgery, Vol 2. Philadelphia: WB Saunders; 1987. p. 1 – 18. Grillo HC, Zannini P, Michelassi F. Complications of tracheal reconstruction: Incidence, treatment and prevention. J Thorac Cardiovasc Surg 1986;91:322 – 8. Grillo HC, Mathisen DJ. Primary tracheal tumors: Treatment and results. Ann Thorac Surg 1990; 49:69 – 77. Grillo HC, Donahue DM, Mathisen DJ, et al. Post intubation tracheal stenosis. Treatment and results. J Thorac Cardiovasc Surg 1995;109:486 – 93. Montgomery WW. Suprahyoid release for tracheal stenosis. Arch Otolaryngol 1974;99:255 – 60. Mathisen DJ, Grillo HC, Wain JC, et al. Management of acquired nonmalignant tracheoesophageal fistula. Ann Thorac Surg 1991;52:759 – 65. Momose KJ, MacMillan Jr AS. Roentgenologic investigations of the larynx and trachea. Radiol Clin North Am 1978;16:321 – 41. Chevrolet J. Helium oxygen mixtures in the intensive care unit. Critical Care 2001;5:179 – 81. Ho AM, Dion PW, Karmakar MK, et al. Use of heliox in critical upper airway obstruction: physical and physiologic considerations in choosing the optimal helium: oxygen mix. Resuscitation 2002;52:297 – 300. Jolliet P, Tassaux D, Chevrolet J. Beneficial effects of helium-oxygen mixtures in acute respiratory failure. In: Yearbook of Intensive Care and Emergency Medicine. Berlin: Springer Verlag; 1999. p. 244 – 51. Gaissert H, Grillo HC, Mathisen DJ, et al. Temporary and permanent restoration of airway continuity with the tracheal T-tube. J Thorac Cardiovasc Surg 1994;107:600 – 6.