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Successful repair of a transected intrathoracic trachea after chest trauma
J
THoRAc CARDIOVASC SURG
91:307-314, 1986
Brief communications Successful repair of a transected intrathoracic trachea after chest trauma Manuel J. Martinez, M.D., Lieutenant Colonel, MC, USA, Robert S. Hotzman, M.D., Major, MC, USA, Victor M. Salcedo, M.D., Captain, MC, USA, and Raul Garcia-Rinaldi, M.D., Ph.D., Tacoma. Wash; and Houston, Texas From the ThoracicSurgery Service, Department of Surgery, Madigan Army Medical Center, Tacoma, Wash., and The Houston Heart Institute, Memorial Hospital System Houston, Texas.
A 28-year-old man had a tramection of the intrathoracic trachea in a head-on collision. Prompt diagnosis with a flexible bronchoscope. expeditious thoracotomy, and distal tracheal intubation proved lifesaving and aUowed for meticulous repair of the disrupted trachea. The patient is asymptomatic 1 year later.
The number of reported tracheal and bronchial injuries has increased during the past decade.' This is probably because of the improved ability of today's emergency medical teams to maintain an airway in the field and transport the victim to centers capable of dealing with such injuries. We successfully treated a case of traumatic transection of the intrathoracic trachea. This was the fourth such case reported, the third case treated successfully, and the first in which immediate diagnosis and treatment resulted in patient survival. We now present the anesthetic technique, intraoperative management of the airway, and the technique for tracheal repair. Case report. A 28-year-old man was brought to our trauma center a few minutes after a head-on automobile collision during which he was expelled from the vehicle. The blood pressure was 130/90 mm Hg, pulse was 130 The opinions or assertions contained herein are the views of the authors and are not to be construed as official or as reflecting the views of the Department of the Army or the Department of Defense. Address for reprints: Manuel J. Martinez, M.D., Cardiovascular Surgery of Texas, 7500 Beechnut, Suite I 10, Houston, Texas 77074.
Fig. 1. Postintubation chest roentgenogram. Note subcutaneous and mediastinal emphysema. Endotracheal tube appeared to be positioned in right main-stem bronchus.
breaths/min, and breathing was labored. He had fracture of the upper part of the sternum with a flail segment surrounded by ecchymoses. On expiration, air extruded from a small laceration over the sternal fracture. Subcutaneous emphysema was present over the anterior portion of the chest, and breath sounds were audible over both lung fields. There was no evidence of major blood loss, including no blood in the peritoneal lavage. A roentgenogram of the cervical spine showed a bilateral pedicle fracture of the second cervical vertebra with anterior subluxation over the third cervical vertebra. Nasotracheal intubation was accomplished to avoid hyperextension of the neck. The patient's condition worsened with intubation, since air exchange through the endotracheal tube was difficult. He became cyanotic. A chest x-ray film demonstrated no pneumothorax and massive subcutaneous and mediastinal emphysema; the endotracheal tube seemed to be in the right main-stem bronchus (Fig. 1). On an inspired oxygen concentration of 1.0, arterial pH was 7.13, oxygen tension 43 mm Hg, and carbon dioxide tension 62 mm Hg. Pulling the endotracheal tube several centimeters improved air exchange, but the amount of air exhaled was significantly less than inspired. His cyanosis improved, but because of progression of subcutaneous emphysema the presence of tracheal injury was suspected. A bronchoscope was rapidly inserted through the endotracheal tube and a tear of the intrathoracic trachea, with a 5 em
307
3 0 8 Brief communications
Fig. 2. Photograph through bronchoscope 2 months postoperatively. Trachea is widely patent. gap between ends, could be seen. This tear could be appreciated only on inspiration, because the mediastinal pleura obliterated the path of aix exiting the distal tracheal segment during spontaneous breathing. The patient was paralyzed with pancuronium bromide, andgentle, positive-pressure ventilation allowed for better air exchange. Bridging the gap with the endotracheal tubewas notattempted because of the danger of pushing the distal segment further away. A right posterolateral thoracotomy through the intercostal space was done expeditiously. When the pleura was entered, ventilation could not be maintained. By rapid, blunt finger dissection, the distal end of the trachea was located and adequate ventilation was established with a sterile 7.0 mm diameter anode tube. The trachea had been transected five rings above thecarina. Thedistal segment was prepared byexcising onetracheal ring. The inferior pulmonary ligament was divided. The proximal endhadretracted to thethoracic inlet; traction sutures allowed for its approximation to the distal segment without tension, and further dissection was not needed. An anastomosis was performed with interrupted 4-0 Vicryl sutures with the knots tied on the outside. After placement of the posterior now of sutures, the anode tubewas removed and the endotracheal tube was advanced into the distal trachea. The front row of sutures was then completed. A large pulmonary contusion and the flail sternal segment made assisted ventilation necessary during the postoperative period. The endotracheal balloon pressure was monitored and kept under 25 mm Hg. Afterextubation on postoperative day 18, thepatient's course was uneventful. Inpreparation forfusion of the cervical spine 6 weeks later, bronchoscopy revealed a widely patenttrachea (Fig. 2). At present, 17 months later, the patient is asymptomatic and leads a normal life.
The Journal of Thoracic and Cardiovascular Surgery
Discussion. The true incidence of transection of the intrathoracic trachea is unknown. Major tracheal and bronchial injuries have been reported in 0.8% to 2.8% of accidental-death victims. In 20% of these the injury is confined to the trachea, and in 21% the intrathoracic trachea is the site of injury.2-4 Injury to the intrathoracic trachea has been reported with increasing frequency." Many patients with these injuries can now be treated at emergency care facilities. In 1966 Chesterman and Satsangi" reported a mortality of 30%, and half of the victims died in the hospital within the first hour. In contrast, in 1979, Grover and associates" reported no deaths among 14 patients with major tracheobronchial injuries. Ecker and colleagues" identified two major factors that influenced survival in their series: the presence of associatedinjuries and the site of the tear. Of 24 patients alive on arrival, only nine had major associated injuries. However, among 70 patients dead on arrival, all had an average of two associated injuries. In the patients alive on arrival, the cervical trachea was the predominant site of injury, whereas in those dead on arrival, the intrathoracic trachea was most frequently involved. Bronchoscopy, the most important diagnostic and sometimes therapeutic tool, should be performed in any patient with a suspected airway injury. If the site and nature of the injury are identified, careful planning of anesthetic and surgical strategy may be lifesaving. Occasionally, the rigid bronchoscope can be used to secure the airway or to bridge the gap between ends of a transected trachea or bronchus. In our patient, we elected not to attempt intubation of the distal segment before thoracotomy for fear of further compromising the airway. Intubation from the operative fieldwas planned, and sterile anode tube and extensions were ready for use when the chest was opened. Three cases of transected intrathoracic trachea have previously been reported." Two of the three patients were successfully treated 24 and 34 hours after injury; the third patient died before the trachea could be repaired. In one patient, stricture developed at the anastomotic site 3 weeks after repair. The authors described mobilization of the trachea from the thoracic inlet to the pulmonary hilum although they avoided dissection on the lateral aspect.' In our patient, we avoided extensive dissection of the trachea: Only one tracheal ring was excised to smooth the edge of the distal segment. The two segments were approximated, with the aid of traction sutures, and the anastomosiswas performed with interrupted, absorbable suture. We have learned from our own cadaver dissections that the vessels contained in the tracheal pedicles
Volume 91 Number 2 February. 1986
Brief communications
309
Fig. 3. Cadaver dissection of trachea with blood supply. Note tracheoesophageal branches in pedicle giving branches that join the distal trachea posterolaterally (curved arrows). Branches to the cervical trachea are seen to join in a more lateral direction (black arrows). L. Larynx. CT. Cervical trachea. TT. Thoracic trachea.
join the distal trachea in a posterolateral rather than a directly lateral direction, as previously described by Salassa, Pearson, and Payne'? and Grillo" (Fig. 3). These vessels enter the tracheal wall at the angle formed by the end of the tracheal ring and the membranous portion. We also observed that a substantial number of vessels from the esophagus join the trachea at its left posterolateral angle. In addition, the anterior branch of the superior bronchial artery often reaches the carina anteriorly and is an important source of collateral blood flow to the distal trachea. 10 We believe that extensive dissection of the intrathoracic trachea should be avoided. In most cases of tracheal transection, the two segments can easily be brought together without tension, and only rarely should additional length be needed because loss of tracheal tissue. The technique we used for repair is similar to that described by Grillo't" and emphasizes the advantages of absorbable, nonreactive suture material. Although 4-0 Vicryl suture was a good choice for our patient, we are now aware of an excellent result with interrupted polyglycolic acid in a monofilament strand. In summary, we believe that the elements necessary for successful management of complete transection of the intrathoracic trachea are prompt diagnosis by bronchoscopy, management of associated injuries, expeditious thoracotomy, minimal dissection over the anterior and posterior aspects of the trachea, and. meticulous repair with absorbable nonreactive sutures.
REFERENCES Hood RM: Gibbon's Surgery of the Chest, Vol I, ed 4, Philadelphia, 1983, W. B. Saunders Company, p 298 2 Kemmerer WT: Patterns of thoracic injuries in fatal traffic accidents. J Trauma 1:595-599, 1961 3 BertelsenS, Howitz P: Injuries of the trachea and bronchi. Thorax 27:188-194,1972 4 Ecker RR, Libertini RV, Rea WJ, Sugg WL, Webb, WR: Injuries of the trachea and bronchi. Ann Thorae Surg 11:289-298,1971 5 Travis SPL, Layer GT: Traumatic transection of the thoracic trachea. Ann R Coli Surg Engl 65:240-241, 1983 6 Akaosi E, Saito R, Nitta S, Fijumura S, Nakada T, Saito H: A case of complete transection of intrathoracic trachea due to blunt chest trauma. Nippon Kyobu Geka Gakkai Zasshi 32:944-947, 1984 7 Lazar HL, Thomasshow B, King TC: Complete transection of the intrathoracic trachea due to blunt trauma. Ann Thorac Surg 37:505-507, 1984 8 Grover FL, Ellestad C, Arom KV, Root HD, Cruz AB, Trinkle JK: Diagnosisand management of major tracheobronchial injuries. Ann Thorac Surg 28:384-391, 1979 9 Chesterman JT, Satsangi PN: Rupture of the trachea and bronchi by closed injury. Thorax 21:21-27, 1966 10 Salassa JR, Pearson BW, Payne WS: Gross and microscopical blood supply of the trachea. Ann Thorac Surg 24: 100-107, 1977 11 Grillo HC: Reconstruction of the trachea. Experience in 100 consecutive cases. Thorax 28:661-667, 1973 12 Grillo HC: Gibbon's Surgery of the Chest, Vol. 1 ed 4, Philadelphia, 1983, W. B. Saunders Company, p 266
THoRAc CARDIOVASC SURG
91:307-314, 1986
Brief communications Successful repair of a transected intrathoracic trachea after chest trauma Manuel J. Martinez, M.D., Lieutenant Colonel, MC, USA, Robert S. Hotzman, M.D., Major, MC, USA, Victor M. Salcedo, M.D., Captain, MC, USA, and Raul Garcia-Rinaldi, M.D., Ph.D., Tacoma. Wash; and Houston, Texas From the ThoracicSurgery Service, Department of Surgery, Madigan Army Medical Center, Tacoma, Wash., and The Houston Heart Institute, Memorial Hospital System Houston, Texas.
A 28-year-old man had a tramection of the intrathoracic trachea in a head-on collision. Prompt diagnosis with a flexible bronchoscope. expeditious thoracotomy, and distal tracheal intubation proved lifesaving and aUowed for meticulous repair of the disrupted trachea. The patient is asymptomatic 1 year later.
The number of reported tracheal and bronchial injuries has increased during the past decade.' This is probably because of the improved ability of today's emergency medical teams to maintain an airway in the field and transport the victim to centers capable of dealing with such injuries. We successfully treated a case of traumatic transection of the intrathoracic trachea. This was the fourth such case reported, the third case treated successfully, and the first in which immediate diagnosis and treatment resulted in patient survival. We now present the anesthetic technique, intraoperative management of the airway, and the technique for tracheal repair. Case report. A 28-year-old man was brought to our trauma center a few minutes after a head-on automobile collision during which he was expelled from the vehicle. The blood pressure was 130/90 mm Hg, pulse was 130 The opinions or assertions contained herein are the views of the authors and are not to be construed as official or as reflecting the views of the Department of the Army or the Department of Defense. Address for reprints: Manuel J. Martinez, M.D., Cardiovascular Surgery of Texas, 7500 Beechnut, Suite I 10, Houston, Texas 77074.
Fig. 1. Postintubation chest roentgenogram. Note subcutaneous and mediastinal emphysema. Endotracheal tube appeared to be positioned in right main-stem bronchus.
breaths/min, and breathing was labored. He had fracture of the upper part of the sternum with a flail segment surrounded by ecchymoses. On expiration, air extruded from a small laceration over the sternal fracture. Subcutaneous emphysema was present over the anterior portion of the chest, and breath sounds were audible over both lung fields. There was no evidence of major blood loss, including no blood in the peritoneal lavage. A roentgenogram of the cervical spine showed a bilateral pedicle fracture of the second cervical vertebra with anterior subluxation over the third cervical vertebra. Nasotracheal intubation was accomplished to avoid hyperextension of the neck. The patient's condition worsened with intubation, since air exchange through the endotracheal tube was difficult. He became cyanotic. A chest x-ray film demonstrated no pneumothorax and massive subcutaneous and mediastinal emphysema; the endotracheal tube seemed to be in the right main-stem bronchus (Fig. 1). On an inspired oxygen concentration of 1.0, arterial pH was 7.13, oxygen tension 43 mm Hg, and carbon dioxide tension 62 mm Hg. Pulling the endotracheal tube several centimeters improved air exchange, but the amount of air exhaled was significantly less than inspired. His cyanosis improved, but because of progression of subcutaneous emphysema the presence of tracheal injury was suspected. A bronchoscope was rapidly inserted through the endotracheal tube and a tear of the intrathoracic trachea, with a 5 em
307
3 0 8 Brief communications
Fig. 2. Photograph through bronchoscope 2 months postoperatively. Trachea is widely patent. gap between ends, could be seen. This tear could be appreciated only on inspiration, because the mediastinal pleura obliterated the path of aix exiting the distal tracheal segment during spontaneous breathing. The patient was paralyzed with pancuronium bromide, andgentle, positive-pressure ventilation allowed for better air exchange. Bridging the gap with the endotracheal tubewas notattempted because of the danger of pushing the distal segment further away. A right posterolateral thoracotomy through the intercostal space was done expeditiously. When the pleura was entered, ventilation could not be maintained. By rapid, blunt finger dissection, the distal end of the trachea was located and adequate ventilation was established with a sterile 7.0 mm diameter anode tube. The trachea had been transected five rings above thecarina. Thedistal segment was prepared byexcising onetracheal ring. The inferior pulmonary ligament was divided. The proximal endhadretracted to thethoracic inlet; traction sutures allowed for its approximation to the distal segment without tension, and further dissection was not needed. An anastomosis was performed with interrupted 4-0 Vicryl sutures with the knots tied on the outside. After placement of the posterior now of sutures, the anode tubewas removed and the endotracheal tube was advanced into the distal trachea. The front row of sutures was then completed. A large pulmonary contusion and the flail sternal segment made assisted ventilation necessary during the postoperative period. The endotracheal balloon pressure was monitored and kept under 25 mm Hg. Afterextubation on postoperative day 18, thepatient's course was uneventful. Inpreparation forfusion of the cervical spine 6 weeks later, bronchoscopy revealed a widely patenttrachea (Fig. 2). At present, 17 months later, the patient is asymptomatic and leads a normal life.
The Journal of Thoracic and Cardiovascular Surgery
Discussion. The true incidence of transection of the intrathoracic trachea is unknown. Major tracheal and bronchial injuries have been reported in 0.8% to 2.8% of accidental-death victims. In 20% of these the injury is confined to the trachea, and in 21% the intrathoracic trachea is the site of injury.2-4 Injury to the intrathoracic trachea has been reported with increasing frequency." Many patients with these injuries can now be treated at emergency care facilities. In 1966 Chesterman and Satsangi" reported a mortality of 30%, and half of the victims died in the hospital within the first hour. In contrast, in 1979, Grover and associates" reported no deaths among 14 patients with major tracheobronchial injuries. Ecker and colleagues" identified two major factors that influenced survival in their series: the presence of associatedinjuries and the site of the tear. Of 24 patients alive on arrival, only nine had major associated injuries. However, among 70 patients dead on arrival, all had an average of two associated injuries. In the patients alive on arrival, the cervical trachea was the predominant site of injury, whereas in those dead on arrival, the intrathoracic trachea was most frequently involved. Bronchoscopy, the most important diagnostic and sometimes therapeutic tool, should be performed in any patient with a suspected airway injury. If the site and nature of the injury are identified, careful planning of anesthetic and surgical strategy may be lifesaving. Occasionally, the rigid bronchoscope can be used to secure the airway or to bridge the gap between ends of a transected trachea or bronchus. In our patient, we elected not to attempt intubation of the distal segment before thoracotomy for fear of further compromising the airway. Intubation from the operative fieldwas planned, and sterile anode tube and extensions were ready for use when the chest was opened. Three cases of transected intrathoracic trachea have previously been reported." Two of the three patients were successfully treated 24 and 34 hours after injury; the third patient died before the trachea could be repaired. In one patient, stricture developed at the anastomotic site 3 weeks after repair. The authors described mobilization of the trachea from the thoracic inlet to the pulmonary hilum although they avoided dissection on the lateral aspect.' In our patient, we avoided extensive dissection of the trachea: Only one tracheal ring was excised to smooth the edge of the distal segment. The two segments were approximated, with the aid of traction sutures, and the anastomosiswas performed with interrupted, absorbable suture. We have learned from our own cadaver dissections that the vessels contained in the tracheal pedicles
Volume 91 Number 2 February. 1986
Brief communications
309
Fig. 3. Cadaver dissection of trachea with blood supply. Note tracheoesophageal branches in pedicle giving branches that join the distal trachea posterolaterally (curved arrows). Branches to the cervical trachea are seen to join in a more lateral direction (black arrows). L. Larynx. CT. Cervical trachea. TT. Thoracic trachea.
join the distal trachea in a posterolateral rather than a directly lateral direction, as previously described by Salassa, Pearson, and Payne'? and Grillo" (Fig. 3). These vessels enter the tracheal wall at the angle formed by the end of the tracheal ring and the membranous portion. We also observed that a substantial number of vessels from the esophagus join the trachea at its left posterolateral angle. In addition, the anterior branch of the superior bronchial artery often reaches the carina anteriorly and is an important source of collateral blood flow to the distal trachea. 10 We believe that extensive dissection of the intrathoracic trachea should be avoided. In most cases of tracheal transection, the two segments can easily be brought together without tension, and only rarely should additional length be needed because loss of tracheal tissue. The technique we used for repair is similar to that described by Grillo't" and emphasizes the advantages of absorbable, nonreactive suture material. Although 4-0 Vicryl suture was a good choice for our patient, we are now aware of an excellent result with interrupted polyglycolic acid in a monofilament strand. In summary, we believe that the elements necessary for successful management of complete transection of the intrathoracic trachea are prompt diagnosis by bronchoscopy, management of associated injuries, expeditious thoracotomy, minimal dissection over the anterior and posterior aspects of the trachea, and. meticulous repair with absorbable nonreactive sutures.
REFERENCES Hood RM: Gibbon's Surgery of the Chest, Vol I, ed 4, Philadelphia, 1983, W. B. Saunders Company, p 298 2 Kemmerer WT: Patterns of thoracic injuries in fatal traffic accidents. J Trauma 1:595-599, 1961 3 BertelsenS, Howitz P: Injuries of the trachea and bronchi. Thorax 27:188-194,1972 4 Ecker RR, Libertini RV, Rea WJ, Sugg WL, Webb, WR: Injuries of the trachea and bronchi. Ann Thorae Surg 11:289-298,1971 5 Travis SPL, Layer GT: Traumatic transection of the thoracic trachea. Ann R Coli Surg Engl 65:240-241, 1983 6 Akaosi E, Saito R, Nitta S, Fijumura S, Nakada T, Saito H: A case of complete transection of intrathoracic trachea due to blunt chest trauma. Nippon Kyobu Geka Gakkai Zasshi 32:944-947, 1984 7 Lazar HL, Thomasshow B, King TC: Complete transection of the intrathoracic trachea due to blunt trauma. Ann Thorac Surg 37:505-507, 1984 8 Grover FL, Ellestad C, Arom KV, Root HD, Cruz AB, Trinkle JK: Diagnosisand management of major tracheobronchial injuries. Ann Thorac Surg 28:384-391, 1979 9 Chesterman JT, Satsangi PN: Rupture of the trachea and bronchi by closed injury. Thorax 21:21-27, 1966 10 Salassa JR, Pearson BW, Payne WS: Gross and microscopical blood supply of the trachea. Ann Thorac Surg 24: 100-107, 1977 11 Grillo HC: Reconstruction of the trachea. Experience in 100 consecutive cases. Thorax 28:661-667, 1973 12 Grillo HC: Gibbon's Surgery of the Chest, Vol. 1 ed 4, Philadelphia, 1983, W. B. Saunders Company, p 266