Surgery of the trachea

c. is Visitin~ Sttrlaeon ~t the Massachusetts Gener:tl Hospital and Associate Clinical l'rofcss~r of St, rgery at l l a r v a r d Mctlic~ll Sch~ol. t l c received his M.D. frt)m il,'trvard :lntl his surgical tr,'tininla zil Massacht~setts General tic, spiral under Dr. E d w a r d 1). Churchill. Doctor Grillo's major investigative interests are in the biology ~f wound healing and in the d e v e l o p m e n t of methods for tracheal reconstruction. His major clinical interest is in noncardiac th~racic surgery, with specigli emphasis oil surgery o f the trachea.

DURING the flowering of thoracic surgery over the past 50 years, surgery of the trachea failed to develop corrcspondingly. The relative r~trity of tracheal lcsions accounts in p~trt for this laggardness. Faced only occasionally with such a challenge, individual surgeons sought ad hoc solutions for each problem rather than a systematic approach. More compelling reasons, however, were ~lnatomic and biologic complexities that thwarted the surgeon who attempted to remove ~lny significant portion of this nonexpendable organ and to achieve a dependable reconstruction. The physiologic problems of management of the patient during a tracheal operation also were formidable, although more easily soluble. Diseases of the trachea that may be considered to be "surgical," whether inflammatory or neopl~lstic, largely present as obstructive problems. Surgical management of these lesions is based on the simple concept of resection of the involved area of trachea and re-establishment of an intact airway, and this demands a reconstrt,ction of the trachea when the larynx has not been lost because of involvement by the primary disease. The requirements for replacing the functions of the trachea appear to be simple. Belsey (9) described the requirements as follows: (1) the tube should be laterally rigid but longitudinally somewhat flexible, to serve as a noncollapsible conduit for air, and (2) the surface should be lined with ciliated respiratory epithelium. Subsequent experience has proved the second criterion to be not nearly as important as was formerly thought. The first requirement is still not easily met, for reasons that will be explained. This monograph concerns itself with the evolution of technics for the safe resection and reconstruction of the human trachea and with those diseases that require such treatment. Problems of the care of the 3

upper airway, respiratory management and medic~ll diseases of thc trachea are not considered. Tracheostomy, the most ancient surgical procedure on the airway, is discussed briclly. After many years of rel~tive inattention, much interest has lately been focused on the surgical managcmcnt of trachc~ll problcms. The field is, therefore, a rapidly changing one. Although effort has bccn made to acknowledge various opinions, ! recognize th~~t the convictions expressed here are personal ones.

DEVELOPMENT OF RECONSTRUCTIVE TECHNICS Primary end-to-end reconstruction of the trachea has been gener,'tlly recognized as the ideal mcthod of repair following resection. Howcvcr, for decades it was believed that a maximum of four trachcai rings only might be excised and primary healing acilieved with salcty (7, 9, 98). As a result, early efforts were dircctcd to the usc of prostheses for tracheal reconstruction. A large but scattered experimental experiencc gradually accretcd. A much more limitcd but, on the whole, discouraging clinical experience with prostheses also developed. In recent years, attention has been focused on extension of the concept of prim~ry st,ture through the utilization of technics for mobilization of the trachea. PROSTHETIC REPLACEMENT OF THE TRACHEA

The belief that only very limited segments of trachea could be resected circumferentially, with safe resuture, led to immense efl'orts in prosthetic replacement. Nearly every type of material h:ls been used. In general, these replacements may be classific0 :~,~follows: ( i ) prosthetic materials, (2) organic transplants ..... both ajutografts ~ind homografts .....and (3) combinations of org,mic transplants with prosthetic materials. The replacement materials were used to patch limited defects following lateral tracheal resection and also as tubular replacements following circumferential resection. Materials that were tried included glass tubes, stainless steel mesh, tubes or coils, tantalum mesh, lucite and polyethylene cylinders, lvalon tubes, heavy Marlex mesh, Teflon and combinations of lvalon, Dacron and Silastic tubes with rigidifying stainless steel wire or firm plastic rings (6, 8, l l, 15, ~7, 20, 63, 67). This list is not exhaustive, but it gives some idea of the ingenuity applied. Use of plastic materials, in general, evolved from rigid tubes to mesh prostheses to, more recently, fabrication of complex prostheses formed of meshes or fabrics supported by interspersed rigid rings. The initial concept of simply providing a noncollapsible tubular airway gradually yielded to,~that of a meshwork prosthesis that was supposed to become incorpoi'ated in the host's granulation tissue. The further theoretical goal was that complete incorporation of the prosthe4

sis by host connective tisstle would be followed by intern~il surf;icing by migr;ttitm of marginal tracheal cr~ithcliunl and that this nlighl, in due lingo, revert to cili~ltcd respiratory cpithclitlm. The inlrath~racic rise or opcll nlcsh or f;lbrics h;is generally required addition;ll supI~orting grafts or flaps of host pleura, pcric;Irdium ~r fascia to provide an inamediately airtight scal. In the upper trachea, seal may be obtained with other adjacent li:;sues, and leakage is of Icss critical importance. Most ~f this work has been done in cxpcrimental animals, including the dog, sheep and other spccies. Variable success has been observed in sh(~rt-term expcrirnents and ew:.n less in long-term experiments. In general, the shorter the length of the prosthetic replacement the greater h;is been the success rate, as judgcd by survival. The dcsired full incorporation by host conncctivc tissue of complex prostheses rnadc princip:tlly of mesh or fabrics usually has not occurred. In successful experiments, the prosthesis remains suit;~t)ly seated and a scaled :~irway is established. H~wevcr, cvcn with prolongcd observation, full incorpor;Jtitm of the nleshwork z~ntt its c¢wcrage by granulation tissue does not occur often, and full epithelializati~m is almost never seen (6, 16, 101, 10")). N~iletheless, a rigid prosthesis may maintain an airway even though ideal healing is not finally obtained. The reason why such solutions have not proved to be vcry satisfactory in the long term becomes evident when the application of thcsc methods in man is cxamined. Alth~)ugh there have been episodic clinical successes with prostheses, including earlier s¢~iid tubes, rcasonably consistent success has not been achieved. Repair of the tr;~chea with prosthetic materials aftcr relatively small lateral resections has been more succcssful. This might have been predictcd, since the continuity of the trachea is not totally interrupted. With circumferential replacement of any length the hazards bccome manifest. Leakage and nonhcaling may lead t~ fatal disruption and mcdiastinitis early after replacement. Dislodgment of thc prosthesis may also lead to early obstruction. Later, the continued chrunic ititlammatory response caused by the foreign body in an inevitably infected ficld leads to obstruction by the formation of granulation tissue and, also, by cicatrization. Death may occur from hemorrhage caused by erosion of major vessels by the nccessarily rigid prosthetic material and the chronic infection that it incites. Failure of multiple scattered clinical attempts at this type of replacement probably have not been reported. We must currently recognize a basic biologic incompatibility in the placement of a permanent prosthesis of foreign material in a potentially infected lield. Almost all the examples of long-term successful clinical use of prosthetics: peripheral vascular, intracardiac, skeletal, neurosurgical shunts~represent the placement of inert foreign material within a naturally sterile environment. When a tube is placed in the airway or gastrointestinal tract, an interface between foreign mate5

rial, repairing connective tissue and txlcterially contaminated epithelium results. A chronic intlamm~tory response occurs, ~nd heckling is unlikely to be :lchicvcd. NtJmcrous atternF~tS have been made to usc pure organic tr,m. pl,~nts, ell her ~lutogralts or homografts. An orth¢~topic ,~utt-gl,~ft of ll';IC}lC:l is needless to say, an experimental procedure. Such experiments arc of importance, since they offer us predictive inft~rmation on the possible value of homografts should tissue transplantation become gencr;~lly more feasible. These experiments have shown that the trachea is too complex and demanding ,! transplant to survive prcdlct,tl 13 even v,'her~ excised and promptly reimplanted in the s:~mc anim~ll (6, I 1,90, 107 ). Blood supply is not regenerated rapidly enough to allow sl~rvival in a high enough pcrccnt:lge of trials. It should also be noted th:tt the I~loott supply of the human trachea is complex enough and line enough so that there is no readily avail~ble dist,lnr, vascul:lr pedicle that would permit future transplantation by rcimplantation of a ~,,~.cul,lr pediclc. Heterotopic autografts have been used with more succes. Thus, cartilage, pericardium, peritoneum, rib,~skin flap with rib c:lrtil:~ge and skin tubes have been variously u._K"cd (21, 35). Many of the,~e replacements have been ingeniously fashioned. Their greatest applic:ltion has been for lateral repair following limited tr:lchc;~! rc,,~ection r.'~ther than for reconstitution after circumfercnti:d excision, Cartilage :~nd ribs have been used in complex grafts to supply necessary splinting. The greatest application of such methods has been in cervic:d trachc:d repair where staging is possible and where leakage is not a lethzll contplication (28). Split-thickness skin grafts have been used to line the luminal surface of some of these complex, reconstructions. When a flap of pleura or pericardium is used as a pa~ch after a lz~teral resection, healing will often progress, with a predictable contraction of the patch. Scar tissue necessarily forms on the uncpithelialized patch and the pre-existing tissues of the trachea at the wound margin are slowly drawn inward, narrowing the trachea to some degree. Since major degrees of narrowing of the airway may be tolerated, it has not always been recognized that ultimate healing of such patches may involve wound contraction (51). Homografts have been largely of experimental interest. Fresh, variously preserved and lyophilized tracheas have been used as orthotopic homografts. The fresh homograft is subject to the same problems of failure of initial survival as the autograft. Where survival has occurred, the graft has been subject to the predictable homograft reaction (11, 24, 42, 59, 107). Preserved and lyophilized tracheas have served as temporary splints but in due time are replaced by scar connective tissue in a biologically predictable::fashion (6, 11, 63). Such a replacement does not serve as a templat"e for restitution of normal tracheal structures. Heterotopic homografts of aorta are similarly subject to ultimate t

'

6

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1~

4,

replacement with sci~r tissue and to stenosis. The air that moves through the trachea does not supply the interned splinting that the pulsating colunlll of blood supplies to a homo~,r~lft in the blood stream. A large number of complex combin~ttions of org~nic transplants and foreign materials has been utilized. Again, the gre~ltest sticcess has been achieved in patching defects after lateral resection. Fascia, pericardium, pleurae, skin, aorta, gelatin sheets, cartilage, gallbl,'/dder mucosa, colon, jejunum and autogcnotls fibrocollagcnous tissues splinted with metal mesh or wire coils hay0 been tried experimentally and clinically (I, 9, 12, 37. 63). Temporary stenting by a glass tube surrounded by :l diced cartilage cylinder and a pleural graft was another solution. Lucite tubes with tracheal grafts were tried early. Polyethylene stents have been used with urinary bladder mucosa, aorta, fascia and gallbl;~ddcr mucosa. Tantalum mesh has been utilized to support dermis, fascia, trachc~fl homografts and autogenous skin grafts and nylon to support fascia or gallbladder wall. The soundest use conceptually of such complex grafts is the total burial of the splinting foreign material within a Connective tissue repl:.,cement. The foreign material then resides within a potentially sterile field, and tissue-to-tissue approximation is obtainable between the trachea and the replacement and betwecn the replacement and the bed of surrounding tissue. The one feature then lacking is a luminal epithelial lining. Unless epithelium is present, healing will occur with connective tissue proliferation; this carries with it all the potential problems of hypertrophic granulations and chronic cicatricial responses. Splitthickness skin grafts have thus been employed (28, 81 ). This requires stcnting and a temporary airway through or below the reconstruction and presents the problems of obtaining complete and full healing of the split grafts. A solution was evolved that used bipedicled flaps of full-thickness skin with fully buried plastic rings for support. This reconstruction met the biologic criteria for repair, but was necessarily a staged procedure of some complexity (43, 50). The technics of primary reconstruction that have evolved in recent years have made lateral tracheal resection and repair largely an unnecessary procedure. Similarly, any but the most extensive circumferential tracheal resections may be repaired primarily in more simple and predictable fashion by mobilization and end-to-end anastomosis. The field for prosthetic replacement has therefore been largely restricted to the few cases in which extensive subtotal resection of the trachea is indicated. Relatively few malignant lesions of such extent are resectable for possible cure, and only the rarest benign lesion is this extensive. An acceptable replacement would be desirable in such circumstances. Unfortunately, despite an occasional success, the basic problem remains a biologic one rather than a matter of ingenuity in constructing 7

and inserting prostheses. The problem, therefore, remains presently unsolved. [~RIMARY RI'CONSTRUCTION WITtlOUT PROSTHESIS

A ntlmber of detailed studies have described the limits c,f tracheal resection in experimental animals ( 13, 30, 64). Relatively few precise tigures were available for many years on lhe amount of trachea lhat might theoretically be resected in nlan and yet permit anastomosis. The anatomies of the human trachea and the c:u~ine trachea do not permit comparison in this rcspcct. Most human figures were based on isolated measurernents at operation, using a variety of plans of dissection that were tailored to each individual case. A small number of anatomic dissections in cadavers were also added. Rob and Bateman (98), in a report c,f 2 cases of reconstruction ~.ff the cervical trachea, noted that the maximal mobilization of cervical Irachea in 6 cadavers allowcd resection and the bridging of no more than 2 cm. without markcd tension. The limits of tracheal resection in man with primary repair were placed at 3-4 rings by Belsey (9) and at 2 rings in an 80-ycar-old autopsy subject by Cantrell and Folse ~'13). Scgmcnts containing 3 rings were succcssfully rcmoved and primary anastomosis pcrformcd by MacManus and McCormick (73). On the basis of canine experiments and measurements of elasticity in 10 human tracheas, Fcrguson, Wild and Wangensteen (30) believed that up to one third of the trachea could be removed and anastomosis effectcd. Roentgcnographic studies showed that flexion and extension of the neck resultcd in a 2.6 cm. difference in length of the supraclavicular trachea (53). Barclay, McSwan and Welsh (7) described excision of 5 - 6 cm. of trachea successfully in 2 patients, by extensive mobilization of the trachea and reimptantation of the left main bronchus into the bronchus intermedius. Michelson et al. (77) carefully examincd the tracheas in 8 cadavers and found that mobilization of the cervical and intrathoracic trachea permitted removal of 4 - 6 cm., that division of the inferior puhnonary ligament and left main bronchus added 2.5-5 cm., for a total of 6 - 1 0 cm. One pound of tension was used. Half as much mobility was obtained in the group over 50 years of age as in the group 3 0 - 5 0 years of age. Grillo, Bendixen and Gephart (48) reported successful removal and reconstruction of a 4-cm. segment of trachea and carina in 1 patient and a 3-cm. segment of lower trachea in another. Miscall et al. ( 7 9 ) reported 2 successful cases of resection for stricture. Grillo, Dignan and Miura (49)~and Mulliken and Grillo ( 8 5 ) s y s tematically investigated in human cadavers the limits of resection of the trachea that might permit primary reconstruction without excessive tension and without destruction of vital blood supply. Two clinical questions were asked: (1) In lesions of the upper hal~ of the trachea,

8

how much trachea could bc rcscctcd and primary reconstruction cffecicd througll a cervical or cervicomediastinal approach alone and Ii(~w lnuch additional trachea, if any, nlight be obtained by extending the incision intc~ the pleural cavity? (2) F(~r lesions of the lower Imlf ()f the tracilca and carina, wh'lt is the am(~unl of trachea that might bc removed and yet permit primary reconstruction by successively m()rc dra,,tic (Icgrccs of nlol:)ilizalion()f lung and hiltzs? Surgeons arc used to thinking of the tr~lchea as it lies in the exposttrc for lhyroid surgery and often fail to recognize that :llrnost the entire trachea bcc~mcs a mcdia.~tinal ~)rg~in by the sinlplc maneuver of llexing the neck so lIlat the cricoid cartilage descends Io the level of the sternal notch. Investigation of the a m o u n t of upper trac/wa tl~:Lt might be removed was cmltluctcd in 15 cadavers, placing lhc neck in what would be comfl)rtabl¢ flexion in life .... 15.-35 degrees. "l'he trachea was mobilizccl anteriorly and posteriorly t() the carina. The lateral connective tissue hearing the blood xupi'dy remained intact. With a standard ten-sion of 1,()()()-!,2()() Gin., it was possible to rescct a median length of 4.5 cryl. (7 ring_,;) !n the subjects (range, 3.5--6 cm.). Such resection is feas,ible thr¢~ugh c'ithcr cervical or cerviconlediastinal incisions without entering the pleural space. Additional llexion of the neck permitted the extent of resection to bc increa,~,ed to 5.8 cm. f 10.2 rings) tinder the same degree or tensi~m, Extension of the incision to the right plcural space, with furlhur mol-~ilizati~m of lhe hilus (~f the righl lung and the inferior pulmonary ligament, permitted 1.4 cm. of additional length (2.5 rings) to be resected and anastomosis performed. l)edo and l=ishman ( 25 ) used laryngeal release to facilitate tracheal "~ m and Klcin (!()6) el(regaled the tractlea experimentally resection. S( by incising partial tllickness of the intercartilaginous ligaments; Narodick, Worman and Pcmberton (88), also in dogs, made alternating lateral hemisections~.to be patched with periosteum for similar elongation. Tl-ie approach to the lower hall of the trachea and carina was examincd in 4(1 adult autopsy subjects of wide age range. With the head and neck in neutral position, full mobilization of the right hiltim with division of the pulmopary ligament permitted resection of 3 cm. (range, 2-4.2 cm.), or 5.9 rings, with reconstruction at tensions well under 1,000 Gin. in most cases. Dissection of the pulmonary artery and vein intrapcricardially to obtain ftirther mobilization permitted the addition of 0.9 cm. (0.3-1.8 cm. ), ;in average of 1.6 trachcal rings. The amount of mobiliz'ation could be increased by a large increment (2.7 cm., 5.5 rings) by dividing the left main bronchus, which is kept from advancement by the arch of the aorta, advancing the right main bronchus and carina upward toward the neck and then reimplanting the left main bronchus into the bronchus intermedius. This last maneuver, first used successfully by Barclay, McSwan and Welsh (7), is best reserved for

9

c~Irinal reconstructions bccausc of t]~c complcxity of the sutt~rc lines. Cervical flexion facilitatcs the extent of rcscction and ease of reconstruction for lesions of the lower trachea also by the descent of the trachea into the mediastinum. The figures given for the lower trachea in these studies are therefore conservative ones. The technics o1' mobilization with primary anastomosis have come into increasing use (43,

65, 87). Two critical questions must be askcd: (1) At what tension is anastomosis unsafe? (2) What degree of mobilization wilt' not intcrf'crc with tracheal blood supply and subscqucnt healing? Cantrcli ~lnd l:~lsc (13) found in dogs that levels of tcnsion below 1,700 Gnl. permitted safety from disruption after tracheal anastomosis. Althc~,t,Jgh the gross anatomies of the canine and hunlan trachea are different, the biologic parameters of tissue repair are similar. In anatomic slutlics in re;in, Grillo, Dignan and Miura (49) found tllztt an average tension of 675 Gin. was required for approximation (m;ixinaum, 1,1()0 Gin.) of the trachea after resection of a 7-cm. length. A few rneasttrements made clinically in the opcrating room have yic.!ded tcnsions of ablaut 600 Gin. for resection lengths of 4.5 cm. In no case htls anastomotic separation occurred clinically due to tension. Separation that has bccn encountered clinically la~s been clearly attributable to other causes. The human trachea has a segmcntal blood supply that is unlike the longitudinal vessels of the c~lnine tr~chca. Miura and Grillo (80) found in anatomic injection studies of 28 autopsy specimens that the blood supply of the upper trachea came largely from fine: branches of the inferior thyroid artery that were distributed to the trachea and esophagus. Othcr vessels supply the esophagtis and trachea in common below this; the bronchial arteries nourish the carina and lower portion of the trachea. Considerable mobilization of the carina and lowermost stump of the trachea has been performed clinically and the short distal segment advanced for successful anastomosis to the stump of the upper trachea. However, circumferential mobilization of a long segment of distal trachea after resection of a section of upper trachca almost certainly will lead to necrosis of the proximal end of this residual distal segment. For this reason, taking into account the point of' entry of the blood vessels supplying the trachea, mobilization of a distal segment that is to be advanced toward the larynx is always accomplished by anterior and posterior dissection only. The lateral pcdicles are carefully preserved. Circumferential resection of the trachea is preferable for lesions of any considerable size. Occasionally, small lesions of the trachea may be removed by either horizo0tal or vertical "wedge" excisions, with direct approximation of the re"rnaining edges. Narrowing of the trachea results, particularly from vertical excision. Horizontal excision may present difficulties, especially in the anterior wall, since the posterior

10

wall may buckle to l'ornl a wllvc-likc structure. More extensive lateral excisions were widely used in the p~lst. Such excisions frequently led the surgeon much too close to a tumor and still let't him with a problem o1' reconstruction.

DISEASES OF THE TRACHEA A more appropri:ltc title for this section would be "Surgical Diseases of the qracl~ca"--to include those diseases that, at least, are potentially surgic~ll. We sllali not consider such medical conditions as tracheitis or tracheobronchitis nor shall we consider the problems of care of the Ul~t~er airway during other acute diseases or following distant trauma. "i'he diseases that are amenable to surgical treatment by rcsection and reconstruction are obstructions duc to neoplasm or cicatricial stcnosis, ~lnd tracheal malacia (loss of rigidity of the tracheal wall). (.'icatricial stem)sis is most conamonly seen as the result of complications of tracheostomy, the more recently recognized and increasingly frequent postventilatory stenosis and, less commonly, stenosis following direct laryngt~tr:lchcal trauma. Tracheal stenosis and bronchial stenosis duc to tuberculosis have become increasingly rare in the United States. Tracheomalacia occurs most often as part of the cornplcx of changes that occur in postintubation injury to the trachea. Malacia may follow lt~ng-term tracheal conlpression by benign goiter. POSTINTU'BATION STENOSIS AND MALACIA

Obstruction of thc upper airway has been seen increasingly as a consequence of respiratory assistance through cuffed tracheostomy tubes. Two factors may account for this apparently rising incidence. First, advances in respiratory care have produced morc survivors of prolonged vcntilatory assistance, which is more likely to lcad to tracheal injury than short-term assistance. Second, clinical awareness of the occurrence of tracheal stenosis and concomitant malacia has increased. Such variables as patient population, duration and methods of ventilatory assistance and specitic care of patients make it difficult to establish an absolutc incidence of these conlpli~,ations. In 1967, 17% of a vulncrable population in the respiratory unit at the Massachusetts General Hospital developed clinical evidence of upper airway obstruction (40). This population consisted of the survivors of relatively prolonged treatment of severe respiratory failure. Excluded from the population were large numbers of patients who received respiratory support for from 24 hours to 3 or 4 days, often through endotracheal

tubes. An additional large population of patients received respiratory therapy in other divisions of the liospital, often for less-sevcre respiratory decompensation than those admitted to the respiratory unit. The figure does, however, indicate a relatively high incidence of potential 11

complication in severely ill patients who survive prolonged respiratory support. The figure compares with that of 20% reported from the Toronto General Hospital (93), 12% of a group of cardiac surgical patients who received prolonged respiratory support at New York's Mount Sinai Hospital (70) and 16% of a group ot" 50 patients from Australia (22). Tracheostomy itself may be associated with many of the complications described later. A significant incidence of stenosis at the tracheostomy site h~s been noted in patients who have been on ventilator assistance I'46, 93). Pearson (91 ) noted that the number of such complications diminished following the introduction of a light, flexible, swivel connector from tube to ventilator tubing ..... to minimize mechanical trauma at the tracheostomy site. The typical stenotic lesion resulting from the use of tracheostomy tubes consists of a circumferential fibrous collar between 1 and 3.5 cm. belew the site of the tracheostomy itself, Varying degrees of malacia--loss of cartilaginous support of the tracheal wall--may result in the segment between the stomal site and the stenosis. Rarely, the degree of stenosis may be small, but partial obstruction may result from intermitten~ collapse of the malacic segment (Fig. 1). E T I O L O G Y . - . . . . Healing of necrosis of the tracheal wall caused by the pressure of the cuff produces the typical circumferential, infraslomal stenosis. The evidence comes from three sources: ( I ) pathologic study of lesions found at autopsy in the tracheas of patients who had had cuffed tubes in place for varying periods; (2) examination of fully developed obstructive lesions that had been surgically removed: (3) experimental reproduction of similar lesions by cuff pressure. Tracheal damage due to cuffed tubes has been described by numerous observers (2, 34, 4I, 108, 110, 111 ). Damage due to erosion by the pressure of ;~ cuff is of much greater magnitude than the superficial mucosal changes following tracheostomy alone (10, 36, 99). The pathology of cuff damage was described in detail by Florange, Muller and Forster (33). In a prospective study, Pearsen, Goldberg and da Silva (92) noted damage uniformly at the site of the cuff, utilizing bronchoscopic observations through the stoma of every patient who had been on respiratory assistance with a cuffed tracheostomy tube. Cooper and Grillo (18) examined the tracheas of 30 successive patients who died while on ventilator assistance administered through cuffed tracheostomy tubes (silver tubes with rubber cuffs and Portex tubes with plastic cuffs) and, also, those of 4 additional patients who died while receiving respiratory assistance through cuffed endotracheal tubes for shorter periods. None of these patients had airway obstruction at the time of death. The duration of tracheostomy was from 1 to 60 days and that of endotraeheal intubation from 4 to 7 days. Significant changes in the tracheal wall were found in every patient at the site of the balloon cuff. The severity of these erosive changes progressed, 12

CUFFED TRACHEOSTOMY TUBES

ENDOTRACHEAL TUBES

1

1 VOCAL CORDS, CRICOID: gronuloma stenosls

STOMAL. SITE: anterior stenosis granuloma malacio CUFF SITE : stenosis,i.e, f i s t u l a .

3UFF SITE" stenosis, t.e. fistula

TUBE TIP SITE: granuloma - (esophageal or) fistula .... arterial

rUBE TIP SITE: gronulomo esophageal or fistula (arterial )

"%,../ I

Fro. l.---Diagram of the locations and types of upper airway lesions evolving from injuries caused by endotracheal tubes and cuffed tracheosiomy tubes.

in general, with time. Up to about 48 hours, only superficial tracheitis with fibrin deposits was seen. Shallow ulcerations of the mucosa overlying the anterior portion of the cartilaginous rings next became prominent. In about a week, the cartilaginous rings were bared and in 10 days to 2 weeks exposure became more extensive, with softening and fragmentation of cartilage (Fig. 2). In most cases, the tracheal wall was distended and thinned at the location of the cuff. The area of maximal damage began about 1-1.5 cm. below the margin of the tracheal stoma and extended from 1 to 2.5 cm. Within 3 weeks or more, cartilage was completely absent in many specimens. Significant tracheitis also occurred around the stoma and between the stoma and area of maximal damage, with thinning and weakening of cartilage. Additional erosions were seen occasionally where the tip of the tube impinged on the tracheal wall. Such erosions were not circumferential and usually 13

FiG. 2.--Tracheal injury due to cuffed tracheostomy tube. Autopsy spechnen of larynx and trachea. ,4, Portex tracheostomy tube, now deflated, h~td been in place for 19 days. B, cartih~ginous rings are exposed and fragmented at the cuff site and the tracheal wall is thinned and distended. The distal ulceration is from the tip of the tube. Similar injuries occur with metal and rubber tubes and rubber cuffs.

were of lesser depth than those seen at balloon sites. Tracheal stability frequently was lost at the cuff level of maximal damage and, sometimes, above this. Tracheoesophageal fistulas ~md innominate artery erosion also occur ( 18, 32, 55, 104). Microscopic examination confirmed the gross progression of changes from acute inflammation to ulceration overlying the cartilaginous rings, inflammatory invasion beneath and through the cartilages, with gradual widening and deepening of the ulcerations (Fig. 3). Cartilages then became necrotic, were finally completely sloughed and, ultimately, no tracheal archiieeture rema~ed. The residual bed was composed of infected granulation tissue. The mucosa adjacent to the areas of ulceration converted to squamous epithelium. Changes beneath tl~e cuffs of 14

~f !=

]5

Fl6. 3.--Evolution of tracheal injury at cuff site. Photomicrographs of autopsy sDecimens. A, initially, there is erosion of the mucosa, e.,~peciaily where the mucosa is compressed between the distended cuff and the firm underlying carlilage. Inflammatory changes that are present are seen within 48 hours. (Reproduced with permission from Cooper, J. I).. and Grillo, I-l. C., Ann. Surg. 163:334, 1969.) B, the cartilages subsequently become bare, fragment and are totally s l o u g h e d ~ a s seen here. Massive inflammatory changes have occurred in the tracheal wall. C, the tracheal wall may become totally replaced by chronic inflammatory and granu. lation tissue. After the cuff is removed, this tissue becomes fibrotic and cicatrizes as it heals, resulting in circumferential stenosis.

enclotr~chc~d tubes were consistent with those seen bene~tth the cuffs of trachcostomy tubes. Since endott'~lcl~czll tubes usu;~lly ~lre m~int~tined for shorter times, the changes were less mt~rked and consistent with those c~loscd by the cuffs of trachcostomy ttzbes left in for a similar period. Lindholm (69.) and Donnclly (26) havc recently dcscribcd simil~lr chtlnges in detail. The specimens from a group of 11 patients who underwent surgical resection of fully developed stcnotic lesions (without prior trache:ll opcr:ttion else~;herc) wcre similarly cx~lmined (18). Four of these were anterior lesions at the tr~aclacostomy site. The bnl~lncc showed ~l typical circumferential tibrous di~lphr;ign~ a few centimeters below the stomal site (Fig. 4). The stcnoses were composcd of dcnse fibrous tissue with varying amounts of fresh granulation tissue on their surf~lcc and with varying degrees of cover~ge by squamous metaplastic epithelium. Untreated stcnoscs usually measured between 1 ~lnd 2 cm. in length. Malacic changes were seen v~lri~bly between the stoma :rod the level of stenosis. Microscopically, the w~ll of the tr~che:~ w~s nearly completely replaced by fibrous tissue at the level of m~ximal d~mage. Thus, p~thologic evidence from both ~trtopsy and surgical specimens pr¢~duces a picture theft is consistent with the development of stenosis FIe;. 4 . - - A , typical circumferential fibrous stenosi,~ at cuff site. The p:ltient h:ld received prolonged ventilation for polyneuropathy. The appear:lnce in thi.s oper~tively resected specimen is that which is seen bronchoscopieally. B, f:lirly Icngth~? stenosis at cuff site which occurred in :~ supr~tcarinal Ioc~ttion bec:~use of low placement of a long tracheostomy tube. This specimen was removed transthor:tcically. The interior lumen is usually much narrower than the extern~d diamcler suggests.

16

as a direct consequence of the healing of erosions caused by tile pressure of the cuffs. Evidence that confirnas this sequence was obtained by the experimental reprodtmtion of similar lesions in dogs (19). Segments of Portcx endotracheai tubes tittecl with 3/,s-inch Rusch latex cuffs were introduccd into the tracheas of dogs, anchoring the tube in place with a wire suture and bringing the side arm of the cuff" out through a needle hole in the trachea and cervical skin to eliminate the added complication of tracheostomy (86). The amount of air introduced into the cuff was just sufticient to allow a ventilatory pressure of 30 cm. of water a level frequently used clinically--without signiticant leak; this w~lume was maintained, q'he erosive changes that occurred were entirely similar to those found in the autopsy series of hunaan tracheas. An early chronic group of dogs that had cuffs in place for I0 days showed changes 3 weeks after removal that varied from complete healing with minimal scarring to persistent ulceration and cicatricial narrowing up to half of the luminal diameter even at this early date. The pressures developed within these cuffs at a ventilatory pressure of 40 cm. of water (29 ram. Hg) were in the range of 200 mm. Hg. This compared with the intracuff pressure of 180-250 ram. Hg measured in simi!ur cuffs in patients on respirators at pressures of 20-25 cm. of water. Shelly, Dawson and May (103) have obtained similar results in experimental preparations. Such experimental findings, when combined with the coincidence of changes at the exact site of the cuff in man, demonstrate conclusively that damage results from pressure necrosis by the cuff. Other factors have been indicted in the occurrence of postventilatory stenosis. However, the only factor that is consistently present and well documented is that of pressure necrosis. Irritant materials may be released from tubes sterilized with ethylene oxide (70). Damage occurs from equipment that has not been subjected to sterilization with ethylene oxide. In our experinaental series, none of the materials were so sterilized (19). The damage has been seen from cuffs made of various types of rubber and plastic and with tubes of metal, rubber and plastic (72). Most patients who develop cicatrization have required prolonged ventilatory support because of the severity of their basic disease. Hypotension has, therefore, been frequent (40). While it seems likely that a fall in blood pressure might more easily allow injury to the tracheal wall because of lower tissue capillary pressures, identical damage occurs in normotensive patients. In 26 such patients seen at the Massachusetts General Hospital from 1962 to 1968, a spectrum of variable factors was analyzed (40). Seventeen patients were in the MGH during the initial illness, which required tracheostomy and respiratory assistance, and 9 were referred from other institutions for surgical treatment. The patients were evenly distributed in sex, and their ages ranged from 16 to 73. The causes of respiratory failure were multiple. The background of pre-existing pulmonary disease varied. Some 17

patients had had short periods of endotraeheai intubation prior to the institution of trachcostomy, which was usually done for ventilatory assistance .... but also for control of secretions. Silver and plastic tubes with rubber and plastic cuffs were used. Tubes were in place for from 4 to 127 days and respiratory assistance with intlated cult's varied from 0 to 1 I9 days. Six required mechanical ventilation for 2 weeks or less, 13 for 4 to 8~,~ weeks and some longer. One patient had an inflated cuff' to prevent aspiration following radical head and neck surgery and had no respirator assistance. The cuff volumes were just sufficient to provide a seal at the respirator pressures required to maintain the patient. Cuffs were deflated every llour. The tracheal stomas were kept as clean as possible and suctioning was performed with sterile precautions. Average inflating pressures of the respirators ranged from l 5 to 45 cm. of water and the volumes of air varied from 2 to 10 cc., with a median of 6.5 co. Despite meticulous care, bacteriologic colonization of the tracheal stoma,,~ was inevitable; Staphylococcus aureus :and Pseudomonas aeruginos:l (B. pyocyaneus) predominated. HypoFension was noted in 8 of 14 patients for whom sufficiently detailed hour-by-hour records; were available to monitor this parameter. These observations support the thesis of direct pressure necrosis. Since remarkable degrees of narrowing may be tolerated by ptttients who are relatively sedentary, many lesser lesions go unnoticed. The spectrum of damage obviously depends on a number of uncontrolled factors. Any result from complete healing to total stenosis or perforation of the trachea may result from such treatment, particularly when prolonged. CLINICAL PICTURE.~Symptoms of upper respiratory tract obstruction usually appear within 90 days following removal of the tracheostomy tube. Occasionally, obstructive symptoms develop while the tracheostomy tube is still in place, from granulations just below the tip of the tube. In one patient, a cicatricial narrowing became seriously symptomatic 18 months after extubation. ,4, small number of patients developed symptoms within 2 days after extubation. The majority became symptomatic between 10 a n d 4 2 days after extubation and a smaller number at intervals of 2 and 3 months. Initial symptoms were progressively severe dyspnea on minimal effort, cough and inability to "clear the throat" and episodes of acute obstruction, which were temporarily relieved by suctioning. If the physician is not alert to the existence of this syndrome, the patient may progress to severe stridor and present with extreme dyspnea, Stridor in an inactive patient may not become evident .until the airway has narrowed to a diameter of approximately 5 mm. or less. Since~any- of these patients are still convalescing from severe illnesses at the time the stenosis presents, such a finding is frequent. A number of patients were initially treated for acute "asthma," without relief. 18

If a patient who has had a cuff tube in place (especially for respirator therapy) develops dyspnea, dilIiculty in clearing secretions or stridor after extubation, he must be suspected of having organic tracheal obstruction. If the period of ventilation has been 2 weeks or longer, the index of suspicion should increase. The greatest danger of nonrecognition lies with tlae p'~tient who develops symptoms after leaving the hospital. "All that wheezes is not asthma." X-ray examination of the trachea provides precise diagnostic information (60) (Fig. 5). I..ateral neck films clearly show upper tracheal def,armities. Many stenoses are intrathoracic (at or below the sternal notch), and routine chest films often do not provide sufficient definition. Selected oblique views will throw the trachea into relief from the other mediustinal structures and demonstrate deformity of the air column. Grid films of the chest may be of help, but laminagrams of the trachea give the most exact definition. The exact extent and location of stenosis in relation to the carina and to an existing or prior tracheal storna should be determined preoperatively. If a tracheostomy tube is present, it should be removed during the x-ray examination. A Fhysici~m must be at band, prepared for immediate replacement ot' a tube. Some patients will close down their airway within 10 or 15 minutes after removal of a stenting tube. A metallic marker at the tracheostomy site helps to localize the level of the lower stcnotic lesion. Considerable anterior derormity frequently is present at the tracheostomy site also. Fluoroscopy of the trachea, preferably recorded on video tape, pm.vides a dynamic picture of the trachea and is helpful in identifying major degrees of malacic change that ma~ occur above the stenosis. Diagnosis of malacia is important, since the degree may be significant enough to require specilic surgical correction at the time of excision of the steno:qs. Tracheograms with contrast medium provide excellent delineation but have not been necessary with the above radiologic technics. We have avoided contrast material, since patients with severe ster~osis may have extremely marginal airways. Tantalum inhalation has been used to outline the airway without running the risk of obstruction (3 1 ). Pulmonary function studies confirm a high degree of airway obstruction, as expected. These measurements are of occasional value in defining other defects in pulmonary function. Bronchoscopy must always be done prior to resection. Since radiologic definition provides enough information to plan the strategy of surgical attack and since bronchoscopy may precipitate an acute obstructive episode in p:ttients with subtotal obstruction, we defer bronchoscopy until the patient has been anesthetized for the definitive operation. Bacteriologic cultures of tracheal secretions are always studied and antibiotic sensitivities established. Since many of these patients have had, complicated medical courses and may have received multiple anti-

19

FIG. 5.--Radiologic views demonstrating tracheal pathology. A, lateral neck x-ray. This view and an anterior neck film will show laryngeal and upper tracheal abnormalities. Here, an anterior stomal stenosis (arrow) is clearly demonstrated at and just below the cricoid level. T h e patient had received prolonged respiratory assistance following an intracranial operation: B and C, oblique chest films. B demonstrates a lengthy stenosis (arrows) preoperatively. A cuff stenosis had been resected elsewhere previo0sly but had recurred. C shows the final reconstruction. Discrepancy in the t~'o ends suggests .,,light narrowing at the anastomosis (arrow). This was completely asymptomatic and did not progress further. D, iaminagram of the tracheal At the upper arrow, the trachea m a y be seen to be slightly narrowed at the site of a previous tracheostomy. Below this, the tracffea is 20

biotic treatment previously, it is desirable to have as much bacteriologic ctat;l as possible prior to surgical invasion of the mediastinum or thorax. TRI.:A'rM~.:N'I'.---The fully developcd circumferential stenotic lesion that produces severe respiratory obstruction normally is not amenable to conservative tre~tment (46, 93). The process of cicatrization theft produces the obstruction is the natural behavior of the scar tissue that has nearly or fully replaced the normal tracheal architecture at the site of injury. Rcpcated dilatation and prolonged stcnting do not reverse this tendency. We have therefore treated such stenoses, as well as a number of anterol;~teral stenoses at the stoma, by resection :rod direct end-to-end anastomosis, when the patient could safely tolerate such treatment. In parti~l or less severe degrees of stenosis, a satisfactory result may be obtained by dil~ltation. Analysis of a series of 9 patients treated conservatively (62) shows that fair results were obtained in only 4. One of these, in the meantime, suffered a perforation from dilatation that required lobectomy; a second had diminishing respiratory function; the other 2 had tracheal lumina of less than half normal diameter. One patient 13ad a poor result, 1 was still indeterminate after t) months of treatment, 2 had died and I had cerebral dcgeneration after cardiac arrest due to airway obstruction. Successful surgical management requires prompt diagnosis, as careful preoperative evaluation as time allows, close attention to the details of preparation mentioned, a trained anesthesia team, precise surgical technic and assiduous postoperative care. Details of operative tcchnic are discussed subsequently. Resttlts o/treatment.~Thirty patients with postventilatory stenosis have undergone resection and reconstruction at the Massachusetts General Hospital from 1965 through 1969. Eleven of these 30 lesions originated following rcspiratory care at the Massachusetts General Hospital. Nineteen patients were referred after varying treatments elsewhere, including prior attempts at reconstruction in 4 patients. Reconstruction w'~as accomplished through the cervical route alone in 16 patients. Eight required cervicomediastinal exposure (median sternotomy), without pleural opening. Transthoracic approach was necessary in 5; this was combined with a cervicomediastinal approach in 3. Two of these patients would now be repaired through a cervicomediastinal approach alone, in the light of increased experience. One patient had a stenosis within 2 cm. of the carina and, in addition, an anomalous right tracheal bronchus to the posterior segment of the right upper lobe just below the stenosis. Posterolateral thoracotomy allowed the best access for this repair. An additional patient with extremely dilated immediately above a stenotic diaphragm that occurred at cuff level. This aged patient had received ventilatory support following multiple complications of a thoracic operation. The stenosis was successfully resected. 21

severe asthma, who had undergone multiple prior reconstructive attempts elsewhere, underwent a 5-cm. resection and reconstruc.tion in stages, using the method of constructing a skin tube splinted with plastic rings. This patient probably would now be corrected through a cervicomediastinal approach. One patient of the 30 died after resection. She had had a complex postcardiac surgical course elsewhere and a repair attempte~l with Marlex immediately supracarinally. Although it seemed that rc'spiratory assistance might be needed postoperatively, the low level of obstruction did not allow continued management by tracheostomy alone, and a desperate attempt at correction was made. Ventilator support was required postoperatively and the anastomosis gave way under the pressure of the cult on the third day. The remaining 29 patient.,, provided 24 good to excellent results. One is classified as a poor result. This patient had a malacic segment abovel the stenosis that was not resected widely because of a very poor pulmonary status. The segment appeared to be stable following the reconstruction, which was not fu+'ther splinted, as was done in another patient. He finally required a splinting tracheostomy. Two patients who had severe postoperative complications required continued treatment, one needing re-resection; results in both are now satisfactory. They have diminished airway diameter but are able to accomplish their usual activities. One of these suffered a hemorrhage from the innominate artery 3 days postoperatively and required resection of the artery. Wound infection followed, with partial separation of the anterior portion of the tracheal anastomosis and narrowing as this healed. The re-resection in the other patient was occasioned by an unforeseen intracricoid abscess found at operation and noncooperation during a postcraniotomy state. One patient who enjoys an excellent result had a partial separation of the posterior suture line that required bronchoscopy and intubation for 24 hours on the eighth postoperative day. She suffered from ulcerative colitis and had demonstrated poor healing after all previous operations. She had had multiple prior attempts at splinting and reconstruction of the damaged trachea prior to corrective operation. Bronchoscopic removal of granulations was necessary cn several occasions following the separation, but she healed completely and has remained asymptomatie. One patient is still under treatment. The lengths of segments resected in these patients varied from I to 5 cm. With the exceptions detailed, primary healing was the rule. No late stenoses or complications have occurred in any patient who obtained primary healing. The first case in this group was operated on in 1965. An additional desperately ill patient, who developed obstruction due to granulation tissue white on a respirator, underwent exploration during the early phases of this study but died before resection could be accomplished. In the same period, 5 patients with stenotic lesions were discharged from the hospital with permanent fenestrated trache-

22

ostomy tubes. Resection was not done in these patients for the following reasons--age, severe myasthenia gravis with repetitive attacks, prohibitive cardioptdmonary disease and refusal to consider operation. One of these patients has been able to have the tube removed after many months. In the others, the injured area of trachea promptly contracts down again when the splinting tube is removed. PREVENTION OF POSTVENTILATORY STENOSIS.~VaFiOtlS methods have been proposed to eliminate the pressure necrosis that now appears clearly to be the cause of stenosis. Such methods include alternating cuffs, uncuffed tubes, spacers to vary the level at which the cult" rests, intermittent inltation of the cuff cycled with the respirator, changes in materials and regulation of intracuff pressure (5, 22, 71). Since the standard cuff is essentially circular in cross section and has a high intracuff pressure when inflated, it deforms the ovoid shape of the trachea when inflated sufficiently to provide a seal at usual ventilatory pressures. In a Rusch cuff, the intracuff pressure may reach 180-250 mm. Hg. Although these surprisingly high intracuff pressures are not necessarily directly transmitted to the wall of the surrounding trachea (4), high pressures are exerted against the tracheal wall, particularly against the deformed anterior and posterior walls. The hypothesis that such pressure leads to necrosis is supported by the earlier-cited pathologic and experimental evidence (18, 19). A soft-walled cuff with a relatively large resting volume was therefore designed. This cuff conforms to the shape of the trachea when inflated, providing a seal without requiring high inflation pressures. In experimental animals, using the preparation described earlier for demonstrating the erosive characteristics of standard cuffs, experimental low-pressure conforming cuffs tested with ventilatory pressures at 40 cm. of water developed pressures of only 20--40 ram. Hg (19). Only minimal mucosal discoloration was found in one specimen at the end of 13 days. No damage whatsoever was seen in other specimens. Conforming cuffs based on this experimental model are currently under clinical analysis at the Massachusetts General Hospital. Carroll, Hedden and Safar (14), in careful studies of the pressure volume characteristics of available cuffs, arrived at a similar formulation of an "ideal" cuff. Geffin and Pontoppidan (39) used "prestretched" Portex cuffs to approximate these conditions. OTHER NONNEOPLASTIC DISEASES

ACUTE INJURY.--The cervical trachea may be injured by either blunt or penetrating trauma. A clean-cut stab wound of the neck may lacerate or even divide the trachea with little adjacent damage. Rupture of the trachea, often with associated laryngeal injury, more ~.omrnonly is caused by such blunt trauma as impaction of the driver's neck against a steering wheel, the fall of a child on a picket fence or the 23

collision of a cyclist with a wire at neck height. Such injuries--especially when there are associated injuries .... may be overlooked initially. Upper airway difficulty and hemoptysis may be attributed to associated injuries of the jaw or chest. Subcutaneous emphysema is a frequent warning sign. Severe respiratory obstruction may appe~r only hours after the patient is brought to the hospital. An open wound of the neck is almost certain to be explored and the injuries identified; blunt injury is less likely to be explored, nor should it be, without specilic indication. Difficulty in inserting an airway through tiae laryngoscope ~r in introducing a bronchoscope in a patient with neck injury who has airway obstruction should raise the likelihood of tracheal separation. The tenuous airway that may exist is subject to sudden occlusion. If an airway cannot be established from above a:~ an emergency measure in such a patient, tracheostomy through the area of injury becomes urgent. If the trachea is completely severed, the distal segment may retract into the upper mediastinum. In this case, the tracheostomy tube is best inserted through the area of injury, so that every bit of uninjured trachea will be saved for subsequent recon:~truction. Once the airway is established, the course of treatment must be decided on. If the injury to the trachea has not fractured or macerated too extensive a segment, primary reconstruction should be considered, with or without accompanying tracheoszomy. Occasionally, tracheostomy alone through a conveniently placed injury may be preferable to repair. It is preferable to debride back badly damaged trachea and resect to essentially uninjured trachea prior to reconstruction. Obviously, minor degrees of contusion may be accepted if these are not likely to lead to later cicatricial narrowing at the anastomosis site. Tracheal injuries frequently are high and at the cricotracheal level. This is a narrow point in the airway and any anastomosis must be done meticulously. Nonetheless, some degree of transient obstruction may be seen, particularly with contusing injuries, and it is well under these circumstances to insert a tracheostomy distal to the repair. Occasionally, a combination of suturing and stenting may be advisable. Fine judgment is required in managing these variable injuries (52, 102). If there is any question about the potential for obtaining primary healing either because of the excessive anaount of contusion locally, the age of the injury, injury to the esophagus, contamination of the wound or complex concurrent injuries to the larynx or cricoid, it may be better not to attempt primary repair. Under these circumstances, a tracheostomy may be placed through the injured area so that good trachea is not destroyed. Following healing and reassessment, a direct end-to-end anastomosis may be done several months later, after the reaction has receded. If there is associated laryngeal fracture, this should be reduced and splinted, preferably over a mold, by an otolaryngologist competent in 24

this type of reconstructive technic. Attempts to reduce and hold complex laryngeal fractures by multiple sutures alone may result in stenosis and malfunction of the larynx. The shattered larynx is best molded when the injury is fi'esh (83, 89). Serious associated injuries may also contraindicate primary tracheal repair, especially if the patient is likely to require mechanical venlilatory assistance. In this case, a tracheostomy through the area of injury will carry the patient through his acute phase, avoid injury to additional tracheal tissue and allow later reconstruction when the other problenls have been solved. Linear lacerations of the intrathoracic trachea or irregular tears associated with bronchial injury may result from severe closed crushing injuries of the chest. Variable signs and symptoms of pneumothorax, hemoptysis or dyspnea may present. The clinical problem is similar to that of closed bronchial rupture, and a high index of suspicion is necessary for diagnosis--most frequently by bronchoscopy. Primary repair is the procedure of choice (56, 102). L,xrE I N , I L I R Y . .... W e liave treated two young men who st,stained upper tracheal fracture during collisions when they were driving sports cars with seat belts unbuckled. In one case, several attempts had been made to repair and reconstruct the trachea. In both cases, tracheostomy had been necessary and had to be maintained, since stenosis occurred in the immediate subglottic region. Both patients had bilateral vocal cord palsies. It was elected to close their tracheostomies and reconstruct the laryngotracheal junction. It is often not recognized that "esophageal voice" is actually a pharyngeal voice and that the role of the esophagus is to produce air for phonation. An intact respiratory tree provides a much more easily controllable mass of air for pharyngeal speech, even in the presence of bilateral cord palsy. The laryngeal airway must be adequate for both speech and normal activities. Arytenoidesis may be required to position one of the cords in a permanent location, which will create an adequate airway and permit satisfactory speech. This is done through laryngofissure prior to repair of the subglottic stenosis. In our patients, the pinning technic of Montgomery (82) was used. Following healing of the larynx: meticulous tracheal repair is accomplished, with care to limit dissection so that any fibers of the recurrent nerve, which might still recover in the long term, will not be severed. Temporary tracheostomy is placed several rings below the area of repair. Usually, the tube may be removed in a week. In these cases, excellent results were obtained, with an airway sufficient to permit activities as vigorous as lacrosse. The speech lacked modulation but otherwise was most adequate. The patients gradually learn to phase their respiration with their speech. TRACHEAL S T E N O S I S D U E T O O T I l E R C A I J S E S . a scattering of patients with tracheal stenosis due to rare lesions may also be encoun25

tered. A rare case of failure of tracheal development has been seen in infants with an airway sufficient to permit life. Some with experience in the neonatal field believe that apparent tracheomal~lcia in infants actually represents the normal softness of the infant trachca subjected to other respiratory stresses. Stcnosis or malacia following tracheostomy in children is one of the dreaded complic~ltions of the emergency airway in the child. Because of the small size of the airway and the ease with which it is damaged, it frequently is difficult to remove zx tracheostomy Once it has been inserted in the inf~mt. Little inform:~tion is presently available about the potential for grc, wth of ~ trachea reconstructed in early childhood. At present, v,,e have therefore deferred reconstructive procedures in children, if possible, until essentially full growth is attained. Stenosis of the trachea may also result from chronic endotr~cheal tuberculosis. This is now an extremely r~re lesion in the United St,'.~tcs. I,ocalized stenosis in the healed stage is amenable to resection and reconstruction. Tracheomalacia in the adult has been ,~een as p;lrt of the complex of lesions following postventilatory damage. Under these circtlmstances, it occurs in the segment between the: stoma and the fibrous stenr~tic cli~phragm. We have generally preferred to rcsect the malacic segment with the stenotic lesion if the patient's condition permitted such a lengthy resection. In patients who required minimal surgic~d exposures because of medical conditions, we eiected to resect the stcnosis and splint the malacic segment by placing pl~lstic polypropylcnc rings in tunnels around tlle trachea. The tr~tcheal wall was then pulled out by nonabsorbable sutures that passed through sm~dl perforations in the rings. The malacic segment was not completely dissected, so that the beds tunneled for the rings were not continuous with one another. The strap muscles were sutured to the trachea at intervals between the rings to help firm up the trachea as assurance if the holding sutures later cut through the tissue. Tracheomalacia formerly was seen more often from long-term compression by benign thyroid goiter. Once the goiter was removed, the softened trachea tended to collapse with inspiration. Temporary tracheostomy was sometimes necessary for severe malacia. When malacia is suspected following remowd of the goiter, the endotracheal tube should be withdrawn to a point just below the vocal cords so that the effect of the patient's own respiration may be observed on the stillexposed trachea. Collapse of a segment that has lost its cartilaginous rigidity may be clearly visualized. Bronchoscopy allows one to visualize the effect on the lumen. We have splinted the trachea in such a paticnt, using plastic rings that were originally devised for cutaneous reconstruction, with good result. In Austria and Switzerland, where large goiters were common until recently, numerous technics for tracheal splinting have been devised. 26

NEOPLASMS PRIMARY NEOPLASMS.--,-Tracheal tunaors usually are diagnosed late (45, 97). The initial symptom is nn incre:lsingly troublesome cough and, later, the insidious onset of progressive dyspnea. Hemoptysis may occur at wu;ious tinms in the course of tim illness. The wheeze that appears may be diagnosed as "asthnaa" because pharyngeal examination, sinus examination and chest x-ray usually appear normal. Retrospectively, a lesion nlay be identified in the tracheal air column on x-ray. Even where hemoptysis has served warning and where bronchoscopy and bronchography have been done in routine fashion, tumors high in the trachea have been overlooked. The appearance of asthma late in life is extremely rare. Unexplained symptoms of cough or indications of upper airway obstruction should raise the question of primary or secondary tracheal neoplasia, despite their rarity. A tumor in tim tipper third ot' the trachea may be demonstrated easily on lateral neck x-rays. Standard chest x-rays may or may not show clearly the shadow of a tracheal tumor.\Overpenetrated grid tilms are of some help and tracheal laminagrams will make a specific identification of level and extent. Oblique x-ray films that show the entire length of the tracheal air column are also useful (61). Bronchoscopic examination exposes the tumor and permits biopsy. If the patient's airway is seriously compromised clinically at the time of presentation, we prefer to clarify the level and extent of the tumor by x-ray studies and defer bronchoscopy to the time of possible operation in order to avoid secretions that may precipitate acute obstruction. A retrospective review of 26 primary neoplasms of the trachea treated at the Massachusetts General Hospital and the Massachusetts Eye and Ear Infirmary showed that two thirds of these tumors were primary squamous cell carcinoma (16 cases), one quarter were adenoid cystic carcinoma (6 cases) formerly called " c y l i n d r o m a " ~ a n d the remainder (4 cases) were a mixed group of benign tumors (45). We have personally seen 22 primary tumors of the trachea, largely additional to the prior group, in various stages of evolution, and these frequency proportions have been maintained. Other primary malignant lesions include adenocarcinoma, muco-epidermoid carcinoma, lymphomas and mesenchymal tumors (23, 57, 97). Benign primary tumors of the trachea may include squamous papilloma, hemangioma, fibroma and chondroma. The last are most often seen at the cricoid level and may be truly tumors of the larynx. Primary squamous cell carcinoma of the trachea may present as an exophytic lesion of limited extent or as an ulcerative lesion that may

extend over great lengths of the trachea (Fig. 6). The tumor may be localized when first seen or may have extended to the paratracheal and subcarinal nodes and mediastinum. These tumors present largely with local symptoms. Although there is relatively little well-defined patho27

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logic material awlilablc for detailed study, squamotJs cell carcinoma appears to metastasize initially to the paratracheal nodes. Our initial retrospective review showed that a majority of ttmse patients died from local causes, primarily airway obstruction. It was hoped that more extensive local resection of these lesicms would lead to a markedly improved survival rate. The rarity of the tumor results in slow accretion of experience. We are now less optimistic about these tumors. A large number of them are obviously highly malignant and invasive when first seen. In these, t,,t.,1 and curative extirpation is not possible except for palliative purpos, ,. Nonetheless, resection has led to longterm surviwtl without known disease in a small number of cases. Dissection probably should encompass the lymph nodes on both sides of the trachea with a meticulous and extended dissection. It is impossible to state categorically wlmther irradiation should be utilized preoperatively (or postoperatively) in these cases. Our present plan is to add irradiation following dissection if the resection has been deemed to be potentially curative. The response of squamous cell tumors to irradiation has been variable, with remarkably good initial results in some cases and almost no response in others of similar histology (57, 100). Adenoid cystic carcinoma (" ' ; n d r o m a " ) may appear to be deceptively benign histologically and c.-.cptively localized c,n gross examination. It is incumbent on the operator to obtain as wide margins as possible and to. rock the resection margins veith frozen sections at the time of operation. Although the previously undisturbed tumor initially displaces adjacent structures rather than invading them, there may be extensive longitudinal infiltration of the tracheal wall itself. Local enucleation and resection of the tumor is bound to fail, even though the usual slow growth rate of these tumors may provide an illusory relief and apparent cure for several years. In our experience, secondary resection of an adenoid cystic carcinoma of the trachea is most unlikely to effect a cure. Pleural seeding and pulmonary metastases commonly occur if the tumor is not fully removed at the initial operation. Surgical exl~erience is small in this group of tumors, but it: seems likely that extensive initial resection without transection of tumor will lead to a FIG. & - - G r o s s specimens of primary tracheal neoplasms. A, squamous cell carcinoma of the lower third of the !rachea. This was removed transthoracically and the patient remains well and without disease 6 years later./3', squamous cell carcinoma of the upper trachea. A seven-ring segment has been resected. In contrast with the tumor in A, this is an ulcerated lesion. The proximal and distal margins were negative, as were the paratracheal lymph nodes. However. the tumor recurred paratracheally in the mediastinum 3 years later and the patieni was treated with irradiation. C. carcinoid adenoma primary in the lowermost lrachea just above the carina. This view approximates that seen bronchoscopically. This tumor was treated by circumferential resection immediately above the carinal spur with direct approximation. This is a rare tumor of the trachea. Adenoid cystic carcinoma ("cylindroma") is more common. It may look like this specimen or be more diffusely infiltrating in the tracheal wail.

29

higher succcs.~ rate. These tumors arc responsive to irradiation in some cases, so that radioth~t'apy is worth while if resection is not possible or recurrence is present. Over-all results of treatment of carcinoma of the trachea are generally discouraging, allhough occasional success justifies a more aggressive approach (20, 43, 57). Only 6 of the 22 cases of primary neoplasms seen, since 1963 were amenable to primary resection and end-to-end anastomosis. Of these 6, 1 patient with a carcinoid ~denoma :lnd I with a squamous papilloma have done well. One patient underwent carinal resection for adenoid cystic carcinoma and is free of disease after 6 years, and of lhc 3 patients with squamous cell carcinoma, 1 is free of disease after 5 years, 1 showed recurrence after 3 years and a third died postoperatively. Four additional patients with very extensive "cylindroma:' were treated by extirpation. Two were seen with recurrence of disease that probably would have been fully resectable initially but had not had appropriate primary removal. One of these died following reoperation and the other is alive with pulmonary metastases. Two others died t'ollowihg extemJed operation. I due to hemorrhage into the lungs following, by-pass with hepar~ntza~ion." """ Skin tube reconstruction was planned in 2 patients with very long squamous cell lesions; I died postoperatively and the other suflered recurrence after 2V2 years. The balance 10 patients ...... were treated with irradiation because of extent of local spread, with variable response. In 2, mediastinal tracheostomy was necessary for palli:ltive airway. Houston et al. (57) reviewed 53 primary cancers of the trachea seen at the Mayo Clinic over 30 years~finding 27 to be epidermoid. 20 mucous gland in origin and 6 of mesenchymal origin. Six patients were treated by resection--either circumferential or l a t e r a l ~ a n d reconstruction, with 3 long-term survivals. Laryngotracheal resection was also applied successfully in 4 instances. Perelman and Korolyova (94) reported good results from circumferential resection in 5 patients and lateral resection in an additional case for a variety ~,f primary tr:~cheal neoplasms. SECONDARY NEOPLASMS.-, The trachea may be involved by carcinoma of the larynx, thyroid, lung or esophagus. Other tumors of the head and neck metastatic to the paratracheal regions may occasionally encroach on the trachea. Extrinsic carcinoma of the larynx may extend for variable distances into the upper trachea. In many cases, the lymphatics appear to be involved. This seems indicated by a small experience with radical re-resection of so-called stomal recurrences of carcinoma of the larynx following earlier laryngectomy. Cure has not been achieved despite radical dissection down to supracarinal levels, establishment of mediastinal tracheostomy and grossly clear margins histologically. Carcinoma of the thyroid may obviously involve the trachea at the 30

time of preoperative investigation. More commonly, the surgeon encounters an area of adherence or invasion of the tracheal wall by the cancer. Intimidated by the problems of tracheal reconstruction, he has frequently, in the past, "shaved off" the thyroid tissue from the trachea and, sometimes, has added irr~:diation postoperatively. We have seen a number of patients in whom a tracheal recurrence years later w:ts the only evidence of residual and recurrent disease. Such involvement has occurred with tumors that are considered to be of relatively low grade histologically, namely papillary carcinoma and mixed papillary and adenocarcinoma, in addition to the more malignant and undifferentiated thyroid tumors. Undifferentiated carcinoma of the thyroid may bc responsive to palliative x-ray treatment; the papillary and follicular adenocarcinoma generally is not. Heavy irradiation has, therefore, served only to soothe the st"~rglcal " " conscience and to make late resection of the trachea hazardous or impossible. When tracheal invasion is considered a possibility in thyroid carcinoma, preoperative laminagraphy should be done and bronchoscopy underta~:e n at the time of operation. The surgeon should be prepared to resect the trachea and perform an end-to-end anastomosis if this is clearly required by extent o f d~sea, " ' S e in a potentially curable " " " cdse. The technics of tracheal reconstruction are now sufficiently well worked out that primary repair should add relatively little to the magnitude of the procedure. Careful case selection is of greatest importance. In general, we have not extended the procedures of tracheal resection to patients whose trachea or carina is involved by carcinoma of the lung or esophagus. Few patients with such extension of these primary lesions are in a potentially curable group. We have therefore not wished to add the hazards of an intrathoracic tracheal resection to what would almost certainly be a palliative procedure at best. In a small number of patients who have undergone a controlled program of preoperative irradiation for cancer of the middle third of the esophagus, followed by rad~ca esophagectomy in the absence of distant metastases, we have removed a small segment of t r a c h e a ~ i f this was the only point of identifiable malignant a~sea.e that would be left in an otherwise apparently encompassing resection. Recent experiences with preoperative irradiation of lung carcinoma supply no reason to extend the indications for airway resection. "/

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OPERATIVE TECHNICS AND MANAGEMENT PREOPERATIVE

CONSIDERATIONS

The patient should clearly understand tile magnitude of the operation, what the possibilities of reconstruction are and the likelillood of either temporary or permanent tracheostomy. He should be informed if multiple procedures are likely to be needed. Preoperative study will 31

demonstrate the level and probable extent of the lesion and, also, whether there is significant m.'dacia in the segment above a stenosis. Pulmonary function studies and preoperative chest roentgcnograms may warn of parenchymal defects other than the upper airway obstruction. If operation is not required as emergency treatment, the patient is introduced to the technics of pulmonary physiotherapy that will help him to evacuat~ secretions postoperatively. Effective--although not explosive cough is desirable in the postoperative phase and will not endanger a well-constructed suture line. Protective antibiotics frequently ;ire given immediately before and during operation and for about 5 d~ys postoperatively in accord with antibiotic sensitivity studies to protect against mediastinal invasion by the organisms that are known to be present in the Open trachea. Patients are instructed to keep their cervical spines gently flexed for 8 - 1 0 days postoperatively. We have not used splints for this purpose but, rather, have secured the patient's cooperation in advance. A tight stenosis could be bronchoscopically dilated immediately preoperatively, but we prefer not to run the risk of initiating bleeding or otherwise traumatizing the airway. As noted earlier, bronchoscopy is deferred until the time of definitive operation. Gentle induction of anesthesia, as described later, has been generally feasible through the tightest airway, without obstruction supervening during the induction phase or early operative phase. The likelihood of need for respirator support postoperatively usually contraindicates repair, unless the anastomosis wiil lie well above the site of a tracheostomy and thus be tmstressed by the respirator. All but upper tracheal lesions are thtis excluded. Lower tracheal lesions can rarely be resected so as to leave sutticient trachea above the anastomosis to allow placement of a tracheostomy tube that will not injure the new anastomosis. Operation is also contraindicated if the patient is not likely to be able to cooperate postoperatively. Occasionally, there may be no alternative to a trial of surgical reconstruction of the airway--depending on the nature and location of the lesion. It must be remembered that there is a place for temporizing or even for permanent management of patients with benign obstructive lesions with a tracheostomy tube passed through a dilated stricture.

OPERATIVE APPROACHES The operative approach depends on the level of.the lesion, its extent and its benign.or, malignant.character. The anatomic~course o f the trachea commences anteriorly in the neck and passes posteriorly through the middle mediastinum to the posterior intrathoracic position. The trachea, surrounded by vital vascular structures, is itself minimally expendable. The blood supply is tenuous and relatively easily dis32

turbed. Approach must be sequential so that irrevocable steps are not taken until the surgeon has decided precisely what he must do. Despite preoperative st,it:lies, the full extent of the disease--particularly when neoplastic---may not be determinable until exploration. The surgical plan may require the possibility of exposure of the lung for anatomic mobilization of the carina. Lesions of the upper part of the trachea are best approached through cervical or cervicomediastinal incisions. Such incisions may be extended into the right pleural space if further exposure is necessary. If it is clear that the lesion lies entirely in the lower third of the trachea, the best approach is a standard right posterolateral thoracotomy. This incision is curved in a long, gentle "S" that begins high paravertebrally to allow easy access to the fourth rib or intercostal space (47). If a cervical or cervicomediastinal approach is to be done initially, the patient is positioned supinely with an inflatable bag beneath his scapulae to obtain extension of the neck in the early part of dissection. If entrance into the right chest may be required, an additional tight rot~ is placed longitudinally beneath the right scapula paravertebrally; the patient is then leveled on the lateral tilt table. Most cases of benign stenosis may be managed through the cervical or cervicomediastinal approach. Malignant lesions, on the other hand, may require an exposure that makes the entire trachea available from cricoid to carina, since tumors may be unexpectedly extensive. For such a cervicomediastinal-thoracic incision, the field includes the neck, anterior chest, both axillae and the right chest. This also permits the preparation of skin flaps, which may occasionally be necessary in extensive neoplasia. Drapes are arranged to permit the surgeons to stand on both sides of the table above and below the partially abducted arms, which are supported in unforced positions to permit access, in the one, for arterial gas and pressure monitoring and, in the other, for intravenous administration. A nasoesophageal tube is helpful, especially during the dissection of stenoses where massive anaounts of scar may fuse the remnants of the tracheal wall to the esophagus. Hyperextension of the cervical portion of the spine will bring nearly half of the trachea above the sternal notch level. The anterior surface of the trachea may thus easily be bluntly dissected to the carina through a collar incision. Particularly in benign disease, added mobilization may be obtained by adding posterior blunt dissection after transection of the trachea. The lower segment of the trachea may then be drawn upward. In malignant disease, such blunt dissection is inadvisable, and the addition of partial median sternotomy provides wider exposure. Usually, division of the upper two thirds of the sternum alone will suffice. If there is any difficulty in dealing with a benign inttammatory lesion through the collar incision, sternotomy should be done promptly. Division of the left innominate vein generally does not help the, exposure, since the vein is easily retracted and the trachea points posteriorly 33

at this level. At times, the collar incision is modified by swinging its ends broadly laterally to begin to form the bases of a bipedicled flap, which may be used either to preserve the anterior chest skin for a mediastinal tracheostomy or to serve as the lower portion of a cervical flap for cutaneous reconstruction of the trachea. If such a reconstruction is considered at all, the initial incision must be carefully planned to save the least hirsute, platysma-bearing skin. Rarely, partial median sternotomy is done underneath a broadly based bipedicled anterior chest wall flap where these possibilities exist. If a permanent tracheostomy in the cervical region is anticipated, the upper horizontal incision may be swung somewhat lower to provide an apron through which the stoma may be created rather than to have,it occur at the meeting point of a T incision. The sternotomy incision may be extended, if necessary, into the right side of the chest, usually in the fourth interspace. This exposure provides access to the entire trachea from cricoid to carina. These three approaches may be performed sequentially as the need for them develops, the first, transverse cervical, providing access for initial exploration of the extent of the lesion and determination of the feasibility of resection, the second, sternal splitting,~ providing exposure for more extensive re~ ,ion, and the third, intercostal thoracotomy, providing further access principally for mobilization, to effect a difficult primary reconstruction. This incision is not, hoWever, the one of choice for the lower third of the trachea. Attention is called to the contributions of Mathey and his associates (74) and of Petrovsky, Pereiman and Kuzmichev (95) to surgical approaches to tracheal resection.

THE UPPER TRACHEA The selection of the cervical or cervicornediastinal approach to lesions of the upper trachea has been explained. If there is an existing tracheostomy, as may be the case in benign stenosis, the collar incision may elliptically circumcise the stoma, which may be excised with the stenosis, if that is close by. Usually, the skin ttap has to be mobilized from the trachea in any case and, if necessary, a new opening made to exteriorize a residual stoma, since the relationships of the trachea to the skin and platysma will be changed following the reconstruction. Following elevation of skin and platysma above and below, the medial edges of strap muscle are exposed and the anterior surface of the trachea is followed downward in-the midline plane into the mediastinum. Dense scar may be encountered at the level of the stoma and also of the stenosis, due to per!tracheal inflammation from the original process. Dissection must be;?delicate, and sometimes intermittently interrupted while retraction is lessened, if the anesthetist senses increasing airway obstruction during the surgical maneuvers. The recurrent laryngeal nerves are deliberately not identified in dissections for benign 34

stcnosis, since an attempt to trace them in the dense scar could easily lead to their injury. Dissection remains close to the trachea, displacing the unseen nerves laterally with the scar tissue. Above, the thyroid isthmus is divided in the midline and the anterior trachea usually exposed to the cricoid cartilage. Special care is required to protect the nerves at the laryngeal level, if the dissection has to be carried this high. Extensive lengths of tr~che~ are not dissected free circumferentiaily lest one c~use necrosis from interference with the fine segmental blood supply. Circt, mferential dissection is done only at, and immediately above and below, the sten::,tic segment to be excised. If access is difficult, the sternum should be partially divided early, rather than risk injury to the innominate artery or compromise with a meticulous anastomosis. The pleura remains intact. The innominate artery may be denscly adherent to the trachea. The esophagus is similarly densely adherent in many cases but, with attention to the plane of dissection and the guidance of an inlying esophageal tube, dissection usually can be carried out without injury. Prompt recognition and repair of esophageal injury will obviate difficulties (Fig. 7). Dissection is completed inferior to an obstruction as soon as possible so that the trachea may be transected earlier than planned should the airway become inadequate during the lnobilization. Frequently, early division of the trachea below a lesion makes dissection of the specimen from the esophagus easier. The exact limits of the stenotic lesion sometime¢ are difficult to identify at exploration despite careful bronchoscopic measurements preoperatively. The vocal cords are used as a usual point of reference during bronchoscopy; these do not lie at the ericoid level but 1-2 cm. above the lower border of the cricoid. The area of stenosis should not be confused with nonobstructing deformities from scars at the location of a previous tracheal stoma. Bilateral traction sutures are placed at least I cm. above and below the lesion so that they will not interfere with the subsequent anastomosis. Upward traction on the lower sutures helps to delineate the lower end of the diseased trachea by causing a slight buckling above the first normal cartilage below the area of darnage. Direct palpation is also useful. In benign disease, the trachea is opened horizontally within the obvious lower edge of the stenotic area in order not to remove excessive trachea. Through this short incision an exact level may be defined and a final transection done at the correct level. While it is best to transect immediately above a tracheal cartilage, it is not a matter of concern if the cartilage is partly bared in the process. The line of transection should be sharp all the way around, without fraying the membranous wall or splintering the cartilage. The distal trachea is next intubated across the operative field with a Tovell tube and connected to sterile corrugated anesthesia tubes that have previously been prepared. Endotracheal tubes of various sizes should be at hand. The cuff is inflated distally to prevent leakage of 35

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FI~;. 7.--Reconstruction of the upper trachea. ,,1, the collar incision permits explor:J.tion of the entire trachea and, in nmny c:tscs, reconstruction. Division of the upper two thirds of the sternum widens the access for lower ¢~r more difficult lesions. B, stcrmll division in this case ires made ;lccess to tile lower trache~ e;~sier. Since the tr~zchea points posleriorly, there is nothing to be gained by divisi¢~n of the innominate vein. The pleura is int;~ct. C, the tr~che~ ;'ms been divided below a stenotic lesion and tile patient intub:~ted directly. This allows easier dissection of a lesion that may be fused to the esoptmgus. D, the technic of anastomosis. Posterolateral sutures are first placed, the proximal tube then advanced from above after withdrawing that in the distal trachea and the an;~stomosis completed. Sutures are gener~tlly tied from front to back, with all knots on the outside. The temporarily approximating lateral traction sutures are not shown nor is the cervical flexion which removes tension. Approach to the entire trachea may be obtained by ~tn extension of the cervical mediastinal incision into the right fourth interspace.

37

blood into the bronchial tree. Once tl~c lesi{m is dissected out, tl~c, upper transccti~m is performed. If the stcnosis ix very high. it i,~ well I~ place a stitch in the tip oI' the tran:;oral cnd~tr;Ichcal tube so th~ it m a y easily bc pulled back down into the trachea thr~)ugh the v~:~cal cord aperture at a Inter stage of the opcrati~+n. ,,\s tl~e ancsthcti>,t flexes tile cervical spine, a gentle but firrn pull is applied ill Opl')ositc directions to both the upper and lower tracti{~n sutures tr~ '~ec who,her the ends of the trachea will approximate without ten,,i(m. If the l'c,,ecti(~n is moderately extensive, dissection anterior and posterior t(~ the tr:tche;t may be required above and below to, prmide sufficient mobility. "llli'~ dissection m a y be carried down tc~ the carina and tip tO tile lnrvnx if done with careful ' ' preservation of tile lateral bl~~od" st~pply. With the Tovell ,tacsthesi,! tube bent f{ rv,,ud out of the wqv. tile posterior and latcra! interrupted anastonu, tic sutures are pl:lccd. If necessary, the tube may be removed intermittently t(~ ,~l]ow greater ease of suturing. The patient nlaintains spontancou~ respiration throughout. Sutures are carefully tagged individually and fixed :,o that their exact order will be knoven and in such a way that the order ,,,,'ill not be disarrayed when the patmnts neck ix flexed during the annst('~mosis. We place a hemostat on each suture and then clip each hemostat to the drapes with a second clamp in radial fashion. Notched holding devices have proved to be less q' .,atlsfactorx.. ' '. since 113e suture,~ may be dislodged when the patient's neck is flexed folimving placemen{ of all sutures. "l'hc lateral and anterior sutures bite through cartilaec' and are placed so that each suture ,,,,'ill require only one passage c,f the needle through the cartilage. The membranous wall is :,trong and holds sutures well• All knots are tied outside the lumen. We prefer fine, strong, nonabsorbable sutures because of added dependability during the actual anastomosis; # 4 - 0 Tevdek has been used most recently but Mersilene was used earlier• A posterior suture that is broken during tying usually cannot be replaced in this operative field without restm~re of the anastomosis. We have had no problem with granulation tissue when knots were tied outside the trachea. The sutures are placed approximately 3 - 4 ram. apart. If there is a discrepancy between the proximal and distal ends, as there may be, particularly with cricotracheal anastomosis, compensation must be made as the sutures are placed. Following placement of the posterior and lateral sutures, the distal endotracheal tube is removed and the transoral endotracheal tube is readvanced by the anesthetist, with the surgeon guiding it into the distal trachea. The anterior sutures are now placed. The patient's neck is next flexed by the anesthetist to a suitable leve! and firmly propped up. Later.al traction sutures are now pulled together slowly by the surgeon and fi'is assistant simultaneously and provisionally tied to take tension off the anastomotic sutures. The ends of the trachea should not be telescoped. It is important to have these traction sutures lying where they will not cross over or interfere with the anas•,

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ton!olic suttlres ;.~s lhey ;Ire lied. The anterior SIltUVCS arc lied. At thi,; stage, the flexed p~sili,:m (~f the neck narr~v,'s the (icld, prcvet,,tine visu;tlizaili(~n of the p(~,;leri(~r sulures. These are tie(! c:lrcfull\, by totlch, st:trling ',vilh the lateral ~mes, whicl~ arc m.(~sl ;.tntcrior, and working sleadilv backwarct. A1 c ~mplclion, lhc anastomosis should be g,irtight and is te:dcd tinder s:tlinc. A : sis t~~ sp..~.d. ~'• it.,; sealing. The basic approach for primacy tt~n;or.~ of the upper trachea i~ the sJnle.'" • t-hx-~t,~:x(.r..-, ' in such a cast:, l;,c'", pos,~ibilily must be con,,idercd, that the larynx may have to be partially o:" wt,,olly rem~ved ai~d that ll~e dissection may have to extend m~ch lower than is indicaied by preoperative r(x;ntgenogra m~. Paratrachea! node dissecti(m sh(~uld bc ,lo~e c~nc~n~i~.anllv. At leas;t t.me recurrent nerve m a y very likely have ',o he s;~criIiccd, even if it is not already nonfunctioning. Subtotal Iracheal resccIion may occasionally have to. be done, wilh lhe likelihood that one will be unable to perform a primary reconstruction unless a pro:~thesis is to be m;cd. T h e possibility ()f a staged skin reconslruction may then be enterlained, if the larynx has to be sacriticed, then a sternal tvdc:leostomv may be anticipa1.ed and appropriate plans made in advance. A final possibility is Ihat the lesion will be irresectab!e for cure in the best judgment of the su,'geon. Palli~ttive irradiatkm then may be variably successful. -} . . , .)-, .,. While !.lcolczative bronch ~;-o. COl)lC" bl~,ps 3 " " , with permanent sections might be helpful, the haz,lld, of excessive bleeding from adenoid cystic carcinoma of the trachea or of worsening of a subtotallv obstructed airway by endoscopic manipulation has made us withhold brcmchoscopy until the need for definitive operation. Frozen sect.ions may be de-. pended on then for diagnosis and arc, in any case, essential to determine the adequacy of resection margins. Adenoid cystic carcinoma, despite its rathe, benign-sounding c o m m o n name of "cvlindroma,'" frequently infiltrates the wall of the trachea considerably above or below the central bulk of the tumor. As with other neoplastic lesions, adequate exposure is important. Median sternotomy usua!ly is requi,'ed for exposure of an upper lrachea! tumor in order 1o determine the limits of the tumor and its resectabilitv before embarking on any irrevocable course. In the case of tumor, the strategy of dissection is opposite from that in benign stenosis. T h e recurrent nerves are idenlified at a distance and nodal and paratracheal tissue excised. Each ca.e "'~ demands a studied compromiee between adequate node di,;section proximal and di,;tal to tumor and preservatien of tracheal viability. The critical slructures that

39

limit the resectability are the great vessels of the mediastinun~, the heart, extensive node metastases (in squamous cell carcinoma) and extensions of carcinoma up or down the right or left main bronchi. Heroic procedures should be undertaken with great caution when one considers the generally poor outlook in these lesions. Where the subcarinal lymph nodes or the paratracheal nodes are massively involved, we have not thought it advisable to perform resection even if it is teclanically feasible. THE LOWER TRACHEA Exploration of the lower trachea and carina is preferably performed through a right posterolateral tlloracotomy clFig. 8). In benign, intlammatory disease, close adherence to tile injured trachea itself will make the dissection safe. Where the approach is for tumor, dissection follows the usual canons for approaching malignant lesions. Smaller lesions may not be easily palpable through, the uninvaded wall of the trachea, except through the membranous; portion. The lower paratracheal lymph nodes and the carinal nodes are accessible through this exposure. If a major resection (more than 4 rings) is anticipated, the major mobilization maneuvers are best done prior to removing the tracheal specimen. The operative field thus remains unencumbered of tubes and traction sutures during mobilization. Such dissection con. • s"~sts of freeing the pulmonary artery and the pulmonary veins from the bronchus and from pleural and connective tissues. The inferior ligamen; is divided. The lung is handled as gently as possible throughout this maneuver. If further mobilization is thought to be required, freeing the pulmonary vessels from the pericardium will aid their upward mobilization. The right main bronchus, carina and left main bronchus (to a lesser extent) may also be loosened considerably to permit both upward displacement and some angulation of the carina from under the aortic arch. The plane of such dissection is in the loose connective tissues rather than hard on the tracheal wall. The upper trachea may also be loosened by some dissection anteriorly and posteriorly. _

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Fro. 8.~- Reconstruction of the lower trachea. A, the trachea and carina have been exposed through a right posterolateral thoracotomy (fourth interspace or rib). If needed, the inferior pulmonary ligament may be divided and the hilus dissected to provide mobilization of the distal trachea. B, the trachea has been transected below the lesion and the left lung intubated across the operative field. The right pulmonary artery may be clamped if there is evidence of significant shunting. C, left lateral and anterior tracheal sutures are being placed. The endotracheal tube across the field may be remgved intermittently for greater ease in placing sutures. D. a long endotracheal tube from above has now been advanced into the left main bronchus and the balance of the sutures placed on the right lateral and posterior walls. E, anastomosis has been completed and a second layer pedicled pleural flap is being placed around the anastomosis. 40

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If the trachea must be transected close to the carina, it is best to carry the patient by intubation of the left main bronchus through the open trachea. This avoids the complexity of devising tubes that would attempt to keep both lungs inflated~particularly when the right lung must be manually compressed to provide access to the operative field. The patient is easily maintained on one lung with the high levels of oxygen given. A protected bulldog clamp temporarily occludes the right p~almonary artery to avoid a major shunt through the unventilated right lung. This becomes of critical importance chiefly in patients with parenchymal lung disease. Close attention must be paid to the level of the endotracheal tube so it wi!l not slip too far down the left bronchus and cut off upper lobe ventilation. Periodic suctioning during reconstruction frees the bronchial tree of blood or secretions that may slip past the cuff. Approximation after resection is aided b y forward flexion of the neck to deliver the upper trachea into the chest and by supporting the weight of the uninflated lung with a pack or the hand. Anastomosis is done as in the upper trachea. When the tube that lies across the operative field is removed, a tube from above is advanced transiently into the left main bronchus. Since most endotracheal tubes are not long enough to traverse the distance from the mouth to the left main bronchus, o.ne must be prepared in advance, sometimes using an adapter to connect two tubes. The posterior sutures are then placed and the zmastomosis completed. The endotracheal tube is next withdrawn to a supra-anastomotic level and the tightness of the suture line tested under saline. The pulmonary artery is unclamped. A long parietal pleural flap pedicled near the mediastinum is elevated and brought around the suture line as a second layer. The lung is fully re-expanded and chest tubes inserted. PROSTHESES AND CUTANEOUS RECONSTRUCTIONS

Our approach to tracheal surgery has sought to avoid the use of prostheses. The variety of materials used and their experimental and clinical applications have been detailed in an earlier section. Depending on the nature of the materials used, the technics of their use must vary. The same principles of reconstruction remain: the reconstruction must be rigid enough to stay open; it must be airtight at the outset, if in the mediastinum; healing must be prompt anddependable. The reasons why prostheses usually fail to meet these criteria reproducibly have been noted. The technics for use of each type of prosthesis, if such use is elected, should be sought in published reports, with special attention to complications anfflong-term results of clinical use. Our method for reconstruction of the trachea in stages, utilizing fullthickness autogenous skin and platysma, with buried plastic rings to give rigidity, has found little use. The method was developed initially 42

for rcpl;iccnlent of the cervical trachea, but we have increasingly found it possible--usu~llly without ¢~pening the pleural spaces--to perform primary reconstruction of the tr~lchea through the cervical mcdiaslinal route by the utiliz~ltion of mobiliz:ltion technics. Because of its limited application, the skin and ring method will be described only briefly. The technic consists of elevating the skin and platysm~l between two horizontal c~llar incisitms that extend widely out to the posterior portion of the neck. Multiple, discontinuous polypropylene plastic rings are buried, with special needles, in the flap between dermis and platysma to provide rigidity to the future tube. This tlap is invaginated to form a vcrtic:~l trough, which is anastom¢~sed superiorly to the cricoid or stump of upper trachea and, inferiorly, to the lower trachea. After complete hc:~ling is achieved and a secondary blood supply established, the trough so formed is cioscd over at a second stage with ~ circumscribing incision that enfolds the skin anteriorly. The lateral skin and pl~ltysma arc then slid over this reconstruction, using relaxing incisions to obtain full-thickness closure over the tube. The defects required by tt~e r~laxing incisions are closed with skin grafts in areas in which failure of full take will not compromise the reconstruction. The method thus providcs an airway composed of the patient's own tissues, supported by foreign matcrial completely buried in a sterile field. At completion, the inner surface of the new trachea is completely epithelialized at the outset and, since full-thickness skin is used, contraction is avoided. The simple incisions and double pedicles gt.,arantee good blood supply to the reconstruction (43, 46, 50). Only three cutaneous skin tubes have been fashioned to date. In each of these cases, i believe that we would now be able to perform the reconstruction by direct anastomosis, using an anterior approach. The patients who have had these tubes completed have had no difficulty in raising secretions. One patient with severe asthma required bronchoscopy on numerous occasions following such a reconstruction as he had prit-~r to the reconstruction. Indeed, he later underwent a tracheostomy through the reconstruction during an acute attack and has been kept open with a button to allow suctioning in repeated asthmatic attacks. A second did well for 2 years until thyroid cancer recurred. The third had difficulty with the lower anastomosis and has since died from recurrent squamous cell carcinoma of the trachea. In two of these patients, the extent of resection was great enough so that the upper portion of the sternum and heads of the clavicles were removed to permit extending of the tube deeply within the mediastinum to the distal stump of the trachea. The method may offer a chance for reconstruction after subtotal removal of the trachea. Lesions that are potentially curable rarely require such extensive extirpation. If the lesion is not potentially curable, the magnitude of the operation, the risks involved and the prolonged morbidity with staged procedures do not justify such heroic "palliative" maneuvers. Unfortunately, the one 43

additional patient in whom total removal of the trachea from cricoid to earina was performed and who underwent first-stage reconstruction developed complications that led to his death prior to completion of the second stage of the reconstruction. This patient had a superficial ulcerating primary carcinoma of the trachea that invoh, ed almost the entire extent of the trachea, but no lymph nodes were involved.

MEDIASTINAL TRACHEOSTOMY Occasionally, the removal of an extensive lesion of the upper trachea, either for cure or where there is no alternative method of palliation, will require removal of the larynx as well as a large portion of the trachea. A tracheostomy must then be established well below the level of the sternal notch. The anatomic position of the lower trachea in the posterior mediastinum makes this difficult to achieve. Multiple solutions offered for this problem have included such technics as passing a cutaneous tube made from suture of crossed flaps to the trachea through a sternal hole (66, 78, 105, 109)'. Failure of healing after this type of airway is established is fraught with the most serious consequences, since the major vessels of the rnediastinum are then subject to erosion. In an effort to simplify this problem, a method was devised to ( I ) eliminate tension on the anastomosis by turning the skin down to the end of the trachea rather than pulling the trachea up toward the surface, (2) avoid tunneling through bone, which lays the sternum ot~n for septic complications and dehiscence and (3) provide the simplest possible tracheocutaneous anastomosis namely, suture of the tracheal stump to a simple circular hole in a well-vascularized skin flap (44). To accomplish these ends, a plaque of upper stern~,n usually divided at the first or second interspace (depending on the length of trachea removed), the first and second costal cartilages and the heads of both clavicles ....is excised through a horizontal incision at clavicular level. The incision is extended laterally to obtain sufficient mobility of the flap. A second horizontal incision i s placed at a distance below this, and a broad skin flap is raised pedicled at both anterior axillary lines. The broad bilateral base of the flap generally guarantees good vascularity. The pleura remains intact. Following removal of the primary lesion and the plaaue of bone described, a circular hole is fashioned at an appropriate point in the midpoint of the flap a n d the flap is depressed to meet the end of the trachea. Anastomosis is performed, using fine chromic catgut sutures from the subcutaneous tissue to the outer layer of the tracheal wall. The skin is approximated td~the trachea with fine nonabsorbable 4 - 0 Tevdek sutures, to give a precise mucocutaneous approximation. These sutures pass through the full thickness of the tracheal wall and the skin. After the stoma has been completed, there often is a defect inferior 44

tO the lower horizontal incision. T h e skin distal to this l o w e r m o s t incision is elevated as far as necessal-y-~-often d o w n to tl~e xiphoid cartilage---to permit direct closure by suture. If there is any suggestion of tension, a third, relaxing incision is m a d e below, so that full-thickness skin lies over the mediastinuna and any skin grafting or scccmd-intcntion healing ,,,,,ill lie naorc nearly at the xiphoid level (Fig. 9 ) . C a t h e t e r s are useful, but the field must be scrtlpulously dried before closure. T h e m e t h o d will also permit m a k i n g a deep mediastinal tracheostomy with the trachea still in continuity. Occasionally, this is indicated in a palient w h o has an obstructing lesion of the trachea below clavicular level that is not resectable and in w h o m the degrce of obstruction

Fro. 9.---I.aryngotracheectomy and establishment of mediastinal tracheoslomy.

,4, the iaryngotracheal specimen. The laryngeal lesion is an extensive supraglotlic mucoepiderrnoid carcinoma. 3"he epiglottis is destroyed. The tracheal lesion is a primary squamous cell carcinoma. It is grossly papillary in character and the photograph does no~ indicate the satisfactory margin of normal trachea below the t u m o r . The strut in the photograph is at the cricoid level. Preoperatively. the palicnt had such severe obstruction that he could only breathe lying on his face. B. mediastinal tracheostorny in the same patient. Indentation where the heads of clavicles and upper sternum have been removed are clearly seen. The full-thickness bipedicled skin flap contains the stoma, which is only 3 cm. from the carina. The mediastinum is completely covered by full-thickness skin. A necessary relaxing incision lies over the sternum; it wits allowed to close by second intention but could have been grafted. A second relaxing incision lies in the epigastritzrn. This patient eroded his innominate artery 2 weeks after the initial extirpative procedure. The artery was resected, the stoma reconstructed and the patient had a further uneventful recovery. This episode accounts for the short horizon',al scars seen at either side of the stoma and for the dual relaxing incisions.

45

is so great that one feels compelled to provide a palliative airway at once. The tield of application for this technic is small und it should bc applied with caution. We have had excellent results when hcnlatoma has not acctlmulatcd beneath the flaps and whcn there h:ts been no sepsis :rod no devascularization of the rcsidt, al trachea. However, the healing of the tracheal cuta,aeous suture line is not as predictable as that of a trachea-to-trachea suture line. In a signilicant numl~er of patients, failureof healing has led to massive hemorrhage from erosion of the innominate artery. Bcall and his colleagues (g) tact the problem of mediastinal airway by using a Marlex tube to extend the airway from a distal stump of trachea to a suprastcrnal position. Although granulation formation persisted for a long time. the open stoma allowed its management with case. Foreign material in this area. however, presents the threat of pressure erosion of the arch of the aorta or innominate artery.

ANESTHETIC MANAGEMENT Tile ideal requirements for anesthesia for major tracheal reconstructive surgery are: ( 1) the patient should be continually well oxygcnatcd. (2) the airway should remain under such control throughout that hasty technical maneuvers are unnecessary and (3) the patient should breathe spontaneously at the conclusion and, preferably, throughout the procedure to eliminate the need for postoperative mechanical support. We have avoided even partial cardiopulmonary by-pass as :an unnecessary complication of operation and to avoid the ant~,.o,~ulants, which may cause lethal intrapulmonary hemorrhage from extensive dissection and manipulation iieeded in the very complex cases in which one may be tempted to use by-pass (3). Anesthesia has been sufficiently simplified so that by-pass seems unneeded. The special problems of anesthesia for airway reconstruction are obvious; our technics were evolved with Doctors Bendixen (48), Geflin and Bland *,,'~

i- fl r

(38). If the accessory muscles of respiration are required for maintenance of adequate ventilation, only atropine is given preoperatively. In other patients, preoperative medication is designed to provide somnolence,

using either pentobarbital and atropine or promethazine. Breathing becomes quieter under sedation, reducing turbulence and airway resistance. Ventilation often becomes easier. A radial artery cannula is inserted for blood gas sampling and direct arterial pressure monitoring. The ECG is monitored continually. With the patient breathing high concentrations o f oxygen from a mask, either halothane is added to the inspired gas or thiop'ental sodium (2~/fi % ) is cautiously injected intravenously. Light anesthesia is maintained with halothane and oxygen. Relaxants are avoided, spontaneous respiration being preserved with assistance when necessary. The larynx, pharynx and tra-

46

chea arc topically ,lncsthetized and the t achca ex~smined witll a ventilating bronchoscopc. The anesthetist should also see the airway at this point to get a precise idea of the problern he faces. After removal of the bronchoscope, anesthetic gases are delivered through a large-bore rubber oral endolracheal tube, which lies above the lesion. If the trachea is malacic, the tube may be passed atraumatically through the softened segment to a p~int above the firn~ obstrLlclitm. It should not be forced past or through a lesion. If a trachcoston~y already exists, it may,. of cou~,Lz,'s" bc used for induction, with transoral intu[ at~on performed thereafter. The initial dis,~ection, whether lhrough the neck or chest, is l.Cl~,formed rapidly but gently. Delicate technic is more important than speed that is accompanied by roughness. If complete cornmtlnication between surgeon and anesthetist is maintained throtzghout, cpisode~ c,f obstruction usually will not occur. Dissection is first directed to a point below the obstruction so that an open airway may be provided should the situation deteriorate. Even ~entlc ". . . . , ,:, ' d~sseclu.,n of the trachea usually aggravates airwav obstruction to some degree. The di,;tal tracheal segment is intul: ated across the operative field with a sterile, cuttcd T~vcii endotracheal tube, which is connected to the anesthetic machine by a Y piece and two length:~ of sterilized anesthetic hose. "f'his anesthetic circuit by-passes the origimd endotracheal tube, which, nonetheless, remains in the proximal trachea. Constant attention must be paid by one of the operative assistants to the position of the second erldol[ra.cheal tuk'c.~. A tendency exists to ad~,,.tnce' ,' • the tube into tlle right main stem bronchus during dissection or, if the lesion is supracarinal anO the tube lies in the left main bronchus, to occlude the left upper lobe bronchial orifice. The management of the tubes during anastomosis taps been described previously. Close monitoring of blood g:,ses with repetitive determinations is essential. Clinical as:~essment of verttilatory adequacy and ar:.erial oxygenation is notoriously unreliable. Prior to relief of the obstruction, high levels of arterml CO., may occur. Ventricular arch3 thmt,ls may bc produced at Pco,e levels of 6 2 - I 40 ram. Administration of 100% ()x3,-' gen gives some protection against transient bouts of obstruction during the early phase of exploration. A steady fall in arterial oxygen gtnd ;.1 rise in CO,.., should alert the team to the need for early opening of the airway distal to the obstruction. Perelman e~' aI. (95) have described their teclulic of making an incision in the tracheobronchial tree distal to an obstruction, insertir~g a ventilatory catheler here, completing the resection and anastomosis above and then closing the distal tracheoston'ty or bronchostomy. We have not found this to be necessary, and prefer not to add another suture line. Geffin, Bland and I (38) have pointed out that shif!s in the p]:,cement of an endotracheal tube during a procedt, re that lead t,~ inadvertent ventilation of one lung will be reflected by ,;udden cl':anges in •

7~j¢

•

47

PAO:~. During breathing of high concentrations of oxygen, the arterial oxygen difference reflects the magnitude of right-to-left s h u n t i n g ~ when cardiac output is stable. There is also a tendency for slow increase in shunting during the course of operation, apart from sudden, acute changes. This may result from summation of incre:~sing atelectasis, low tidal volume ventilation and the inevitable aspiration of blood. Slight head-down tilt and frequent tracheal suctioning are advisable to minimize aspiration. Regular deep breaths are administered to reinflate aiveoli. The occasional need for temporary clamping of the right pulmonary artery when the right lung is no~ ventilated has been noted previously.

POSTOPERATIVE MANAGEMENT Although we consider the likelihood of need for postoperative respirator support to be a contraindication to tracheal reconstruction, we prefer to have these patients cared for in .the first week in ~tn intensive care unit with a respiratory orientation. If the reconstruction has gone smoothly and precisely, the course usually has been uneventful. Pulmonary physiotherapy and encouragement of cough generally keeps the tracheobronchial tree clear. However, secretions may accumt~late, especially between the third and fifth days, and require suctioning. If done with care, tracheal suctioning will not damage the suture line. Tracheostomy is avoided because it may lead to drying of secretions, septic complications in the neck and pressure on the suture line. When an old stoma is still open above the area of repair, we use it for suctioning as needed. Inspired air i~ kept well humidified, ~nd supplementary oxygen by mask is used for a few days. A port~ble chest film following operation will help to identify unexpected pneumothorax, atelectasis or blood in the lung and serve as a baseline if complications ensue. The patients are kept moderately dry in body water, to lessen tissue edema. Occasionally, diuretics are used. Diet is advanced slowly to prevent aspiration. The patient is permitted to get out of bed in a couple of days, keeping his neck flexed. X-ray films of the trachea usually a simple oblique view---are taken prior to discharge to confirm the adequacy of the lumen. The patient is allowed to extend his neck gradually and is discharged on no special regimen except a room humidifier at night for a time. Follow-up x-ray studies usually are obtained in a few months. No patient who has had an uneventful operation and hospital course has had late difficulties with the suture line. COMPLICA'I'iONS. Only ~,those complications that are specifically related to tracheal reconstruction are discussed here. The most serious immediate complication is the requirement for respiratory support for more than a few hours postoperatively. The patients are managed so 48

that they breathe spontaneously inlmediately at the conclusion of the operation. Thc airway is kept clear postoperatively (as well as intraoperatively) and great care is taken to prevent atelcctasis and to aw~id all factors th,'tt might lead to the need for mechanical vcntil~tion. The one patient who required ventilation .... and this patient had becn operated on because of lack of any alternative, despite recognition that ventilator suplgort was iikely~had an almost predictable separation c~t' the suture line due to the pressure of the cuff, which had to rest against the suture line in a markedly foreshortened postoperative trachea. Sep~~ration at the suture line is an exceedingly gravc problem. In every c~lse in our experience in which separation has occurred following primary end-to-end tracheal rep."iir the cause has been identiiiable. One case h~s just been noted. In a patient in whom ,q calculated risk was taken to remove an obstructing t'ocus of follicular thyroid cancer that h~td recurred 6 years after previot~s treatment, at a level below the clavicle, but who had unfortunately received 60()0 R of local irradiation, necrosis and separation followed. A third partial separation occurred following re-exploration for control of hemorrhage from the innominatc artery 3 days after the original reconstruction. The wound of re-exploration became septic, exposing the anterior portion o1' an~stomosis, which opened after 4 d,'lys of cxpost, re. The t, nexposed posterior portkm remained intact. A fairly satisfactory airway finally resulted without further operation. A fourth partial separation occurred posteriorly on the eighth day in a patient whe had ulcerative colitis and had notoriously poor healing of previous surgical incisions. A posterior flap of mucosa was elevated and, after this had been observed bronchoscopically, the patient was intubated across the suture line for 48 hours, dehydratcd with ethacrynic acid and, thereafter, made an uneventful recovery. She required transbronchoscopic removal of granulations from the posterior portion of the suture line on several occasions before obtaining smooth llealing. For this reason, we have been loath to discharge such patients, well as they seem, earlier than 8-10 days after operation. One paticnt required reanastomosis at a later date; his first taryngotracheal repair was compromised by the discovery at operation of a previously unidcntifiable intr~lcricoid abscess in relation to a high tracheostomy with stenosis. The eliminatioa of prostheses avoids most erosive damage to the great vessels of the mediastinum-~ in particular, the innon~inate artery, which crosses the trachea obliquely anteriorly. The one patient who had such erosion following primary repair appeared to have a pinhole opening that could have resulted from injury ~lt the original operation. This was successfully controlled without neurologic deficit by excision of the artery and oversewing the proximal and distal segments of the artery with two layers of fine silk sutures. Sternal division at the original operation to allow more working space probably would have 49

avoided this complication. Massive and fatal hemorrhage has been encountered, however, following mediastinal tracheostomy when primary healing of the trachea to the skin has not beera obtained. In such cases, separation of this tracheocutaneous suture line may lead to cicatrization during healing, which, in turn, requires replacement of a tracheostomy tube--usually of plastic. Such a tube resting on the immediately subjacent innominate artery or aortic arch is prone to cause erosion. Two patients have died from this complication. This is, unfortunately, a well-recognized complication c3f mediastinal or "sternal" tracheostomy. Immediately postoperative air leak from primary anastomosis has been seen in only 1 patient, with primary squamotls carcinoma. This sealed after 24 hours. The patient, however, progressed on to a diltu~c pneumonitis and succumbed rapidly, although the specitic bacteriologic etiology could not be established. Despite the consistent presence of Staphylococcus aureus, Pseudomonas aeruginosa and other organisms at existing tracheal stomas and in granulating stenotic lesions, septic complications have not been a problem. The injured tissue is completely excised at operation, with great care taken to avoid hematoma or devitalization of tissue. Immediately before, during and after operation, the patients have received antibiotics selected after sensitivity studies. The patient with ulcerative colitis who had extreme difficulty with healing of all incisions in all parts of the body and who had freshly controlled sepsis around her tracheostomy at the time of excision and reconstruction develol.~ed superficial wound infection (as well as the partial separation noted). Mediastinal, deep cervical or intrathoracic sepsis has not occurred. One patient with laryngotracheal ahastomosis, after a partial removal of the larynx and upper trachea for late recurrent carcinoma of the thyroid--developed a noncommunicating wound sinus that required later drainage as an office procedure. Late stricture of end-to-end anastomoses that have healed primarily has not been seen. One "exception" was in a referred patient in whom, in addition to the usual technic of anastomosis described, the surgeon had supported the anastomosis with Teflon pledgets. A massive cicatrieial response involved these pledgets, forming a collar of stenosing scar. After re-resection and reanastomosis, the patient had no further difficulty. In our earlier cases, in which some of the knots were tied inside the lumen, granulations occurred, which were removed bronchoscopically. If malaeia is present in relation to a benign stenosis, it is best excised so that simple reconstruction may be performed. In a patient whose resection was limited by poor pulmonary reserve, and in whom the malacie segment was neither excised nor splinted, recurrent collapse tinally required the compromise of permanent tracheostomy. 50

THE PROBLEM OF TRACHEOSTOMY Tracheostomy has moved in its long history from a position as the prime emergency measure for relieving upper airway obstruction to a handy method for control of unmanageable secretions to increasing use in management of respiratory insufficiency. The causes of the last are multiple and include pulmonary infection and other loss of parenchymal function, brain injury with central depression, toxic ingestion, unstable chest wall due to trauma or operation and postoperative pulmonary insufficiency. As tracheostomy increasingly has been used for prolonged tracheal support, an alarmingly high incidence of complications has been recognized (27, 29, 54, "75, 76, 84). It is almost a precious statement to say that the best way to prevent the complications of tracheostomy is to avoid the operation (96). While tracheostomy should not be withheld too long, it should never be performed without clear indications. Adequate humidification, effective employment of skilled pulmonary physiotherapy to promote effective cough and carefully supervised use of postural drainage may serve to control heavy secretions. Tracheal suctioning is an effective but sometimes dillicult technic. Transcricoid instillation of saline may be helpful. For treatment of immediate postanesthetic respiratory depression and for support in the first few days, particularly when a chest or upper abdominal incision has temporarily depressed respiratory mechanics, a residual inlying endotracheal tube or its more comfortable alternative--the nasotracheal tube ..... is of value in awfiding tracheostomy. While it may be argued that a tracheostomy maintained for short-term support carries few complications and that the endotracheal tt, be has its own hazards, the balance would seem 'o favor the use of the endotrachea! tube under constant watching for a period of about 4 or 5 day,;. If it then becomes clear that traeheostomy will be needed, the procedure is done electively. Obviously, organic obstruction a t the laryngeal level requires tracheostomy. Often, however, upper airway obstruction is only partial, and tracheostomy is not necessary as an initial emergency procedure. There are few indications now for emergency tracheostomy. The patient's airway usually is most safely and expeditiously restored either by endotrachea! intubation transorally, using a laryngoscope, or by introducing a bronchoscope with a ventilating side arm. Either maneuver establishes a secure airway and gives the surgeon time to evaluate the problem, to perform a tracheostomy in an elective and unhurried fashion~subject, therefore, to fewer complications ..... or to proceed on to concomitant medical problems of greater urgency. Such a methodical approach eliminates most of the immediate complications of tracheostomy. The hypoxia that is associated with obstruction is promptly relieved, reducing the likelihood of cardiac arrest. 51

Prompt establishment of an airway is so important that all surgical house officers should learn the technics during internship. Local anesthesia is preferable for the tracheostomy. If possible, an anesthetist should be in attendance to provide oxygen and ventilatory stlpport through the endotracheal tube, to manage its withdrawal in precise coordination with the insertion of the tracheostomy tube and to give supplemental anesthesia if needed. Hemorrhage during trachcostc~my should be avoidable with the careful exposure possible during unl~urried elective tracheostomy. Postoperative bleeding is climinalcd if thc same care is taken with the procedure as with other "majt'~r" o[)e~",~tions, u o , t:~ tracheotome procedures are to be condemned. Injuries to the carotid arteries are too great a possibility and much too serious to justify the questionable saving of time with such mcthod,;, q'hc methodical performance of tracheostomy will also eliminate the pn~l~lems of mediastinal false passage and most pneumothorax. Damage to recurrent nerves or esophagus during ttacheostom3 should not occur. " - t ~. Careful attention to details of selection of a tube of the proper s~,,c and angulation will avoid its prying on the lracheal walls and it~ placement in the right main bronchus. Early dislodgment of the tube is generally avoidable if the tube is well seated and is of appropriate shape and size. We prefer to use both ties from the flange of the tube around the patient's neck and, in the first 5 days, sutures from flange to skin. Dislodgment or deliberate removal after a tract has been well established in 5 days does not present the problems of replaccmcnt seen ir! the first few days. While other maneuvers are possiblc, such as suturing the skin margin to the edge of the trachea, removing a window of trachea or placing traction sutures in the edges of the trachea, wc have not found these to be necessary where careful technic is t, sed and the flange is attached to the skin. An inner cannula that may be removed for cleaning is presupposed. Slippage or prolapse of a cuff from a metal tube may be avoided by selecting a cuff that fits so tightly at it,; margins that a stretcher is needed to fit it to the tube. The cuff shcmld not be placed so close to the tip of the tube that it can prolapse over the end if slightly overinflated. The balloon should be tested before the tube is inserted a n d a g a i n after it "nas b e e n " m ~erted, • since the cuff may be perforated either by a sharp instrument or the jagged edge of a cartilage. Suctioning of the trachea should b e performed immedia!ely after the tube has been inserted to clear out any blood and secretions 'hat may have entered the trachea during the procedure and also to be certain that an initial toilet is performed of the lower tracheobronchial tree. Prolonged suctioning is to be avoided, as it may create a transient hypoxia. Our technic for performance of a tracheostomy is simple. A short horizontal incision is made through skin and platysma approximately over the level of the second tracheal cartilage, with the patient's neck extended. The strap muscles are separated in the midline at a level 52

below the cricoid cartilage. Precise identification of tile tracheal level is made by using the cricoid as a reference point. The thyroid isthmus often may be displaced downward or upward to expose tile second and third tracheal cartilages antcriorly. Usually, the isthmus is divided by dissecting gently beneath it, dividing it between hemostats and suturing each side. We make a vertical incision through the second and third cartilages. The first cartilage is veO, care/tdly saved, since injury to it may easily erode upward and lead to the difficult problem of subglottic stenosis (58). The opening must be adequate, since the elbow of a tube may depress the upper margin of the stoma posteriorly and also cause subglottic difficulties. If more room is needed, the fourth cartilage is also divided. When the incision is made, the inlying endotracheal tube or bronchoscope is withdrawn to a point just above the stoma. The provisional airway is not completely removed until the tracheostomy tube has been seated and proved to be satisfactory. There is no compelling reason to create windows or flaps in making a tracheostomy. While small windows may not create a defect any larger than that which results from the vertical slit, too often use of the window technic leads the surgeon to make too generous a hole in the anterior tracheal wall. This probably contributes to the incidence of late anterior stomal ol~struction as the gap closes by cicatrization. The :mbseqaent management of the tracheostomy tube is intimately tied to the problems of respiratory care. Adequate humidification, suctioning as required, periodic ctean3ing of the inner tube with it,; prompt replacement or infrequent changes of the outer cannula are required. The stoma should be kept as clean as possible and suctioning done with aseptic technic. Local contamination is inevitable. Rare invasive cellulitis or true necrotizing infection alone demand antibiotics. Feeding is given cautiously, starting with clear liquids, since swallowing is often not wholly normal at this time. This avoids the further hazard of aspiration-~despite an inflated cuff in lungs already endangered by breakdown of the normal laryngotracheal barrier. Tracheostomy tubes that are placed too low may lead to erosion of the innominate artery by direct pressure, particularly in children, in whom the artery is often high in relation to the sternal notch. The tip of the tube or its cult may also erode into the innominate artery by the same process, described earlier, that erodes into the esophagus. Obstruction may occur while a tracheostomy tube is in place. Cuff prolapse has been mentioned. Crusts may block the inner tube. Cleansing the inner tube alone will not prevent all crust obstruction, since crusl.s may form at the tip of the outer cannula. If such a crust acts like a valve, a suction catheter will pass without relieving the obstruction. Prompt change of the entire tube is necessary. If this is early after tracheostomy, the change may have to be made over a guiding cathetdr in the tube to be removed. The possibility of needing to re-explore the 53

w o u n d (in the first 4 days) to replace the tube must be kept in mind and a bronchoscope should be at hand. The problems of postextul)ation obstruction due to granul. ~m,l' or anterior stenosis and deformity at the stomal level or to infrastomal stenosis with o r w i t h o u t malacia have been discussed. With these com191matlon., . • ' s as with the others mentioned, the key to st~ccessful treatment is the awareness of the possibilities, prompt rec~gnition nf signs and symptoms ~!nd prompt corrective action. Occasionally, a tracheal stoma will pt.~slst. The f,tclors lhat lead to persistence are not well defined but may in,elude poor nutrition during a prolonged illness, high doses of steroids, prolonged maintenance of the original tracheostomy and loss of much tissue at tr;wheost(mly. There is no urgency to close such a stoma. If it fails t(, ctnse sporllanc -. ously, repair is indicated for ,:~ "~ sn~et~c -" '" rca,ons -,,- ' and bcc.au, , .... s,c it lead~, to (.ll 11 I C--" U t ""~," tl~..,, ; n , ~ n e e c . h increased tracheal ,~ecretin,, ,~nd p,,ssiblv, haz. • ° ~,r'

|

•

ards of pulmonary infection. The stoma may be closed in a variety of ways: including excision of the cutaneous sinus that joins the respiratory epithelium, approximation of the sl.¢ap muscle:; ,and clo~,ure of skin and platysma. Occasionally, this leads to t'orm:~tic, n of another g r a n u l o m a at the internal site prior to epitheli"al~zatu "" "~n bv lhe tracheal epithelium. Lawson and Grillo ( 6 8 ) . thcref~ r e~, " • devised a siml'ne' ~Tmcstage m e t h o d of closure that utilized the alreadv-existine~, ct~tanctt>' ' '~ stoma as a first-stage tlap. T h e stoma is circumcised, this edge carefully elevated, leaving it attached, however, around the ,,t~,m,t' itself. A 4 - 5 - r a m . circular flap is thus elevated. Great care is tuken nc~t t~ devascularize it by dissecting too close to the stoma. !nvcrsi~m of this skin with a fine, continuous subcuticular, absorbable suture forn~s a fully epithelialized inner layer for the trachea. If the flap is cxce:~sivc!v large at any point it is very carefully trimmed during the closure. Strap muscles are then a p p r o x i m a t e d and skin and platysma closed transversely after extending the lateral ends of the incision slightly.

ACKNOWLEDGMENTS I wish to recognize the contributions to varMus phases of the developmental work reported in this monograph that were made by numerous associates, including D~,s. Joel Cooper, Ellen Dignan, Bennie Geffin, Dexter Lawson, Tsuyoshi Miura and John Mulliken; the anesthetists who helped to evolve the clinical technics of anesthesia, Drs. Henrik Bendixen, John Bland and Bennie Geffin; Dr. Alexander MacMillan, Jr., whose radiologic studies have been invaluable; Dr. H e n ning Pontoppid.an and his colleagues, who helped in the postoperative care of many patients in the ~espiratory Unit. Work described was accomplished with the assistance of grants no. FR 0 5 4 8 6 f r o m the U.S. Public Health Service and nos. 42D and 42E from the American Cancer Society. 54

R 17.F E R E N C ES

1.

2.

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9. I0,

11. 12.

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18.

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....

12"

"

•~

•

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g

1969.

20. 21. 22.

C o t t o n , B. H., and P e n i d o , J. R. F.: Resection of the Irache:~ for carcin o m a . R e p o r t of two cases, .I. T h o r a c i c Surg. 2 4 : 2 3 1 , t95".-. C r a f o o r d , Co, and E i n d g r e n , A. G. H.: Ce.,vical t r a c h e a l , ¢ c o n q : ' u c ~ i o n with skin i m p l a n t containin!, c a r t i l a g e , A c t a chir. s c a n d i n a v . 9 2 : 4 8 1 . 1945. C r o s b y , W . M." A u t o m a t i c i n t e r m i t t e n t inflation of tracheo.~4omy-iubt: cuff, L a n c e t 2" 509, 1964. 55

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72. Lunding, M.: The tr~cheotomy tube ~lnd postoperative tracheotomy complications, Acta anaesth, scandinav. 8:18 I, 1964. 73. MacManus, J. E., and McCormick, R.: Resection and am~stomosis of the intrathoracic trache;/ for primary neoplasms, Ann. Surg. 139:350, 1954. 74. Mathey, J,, Binet, J. P., Galey, J. J., Evrard, C., l.emoine, G., ~md Denis, B.: Tracheal and tracheobronchial resections, J. Thoracic & C~rdiov:ls. Surg. 51 : 1, 1966. 75. McClelland, R. M. A.: Complications of tracheostomy, Brit. M..I. 2:567, 1965. 76. Meade, J. W.: Tracheotomy~its complications and their man~gement, New England J. Med. 265:519, 1961. 77. Michelson, E., Solomon, R., Matin, I.., and Ramirez, J.: Experiments in tracheal reconstruction, J. Thoracic & Cardiovas. Surg. 41 : 748, 1961. 78. Minor, G. R.: Trans-sternal tracheal excision for carcinoma, J. Thoracic Surg. 24: 88, 1952. 79. Miscall, L., McKittrick, J. B., Giordano, R. P., and Nolan, R. G.: Stenosis of trachea; resection and end-to-end anastomosis. Report of two c~ses, Arch. Surg. 87:726, 1963. 80. Miura, T., and Grillo, H. C.: The contribution of the inferior thyroid artery to the blood supply of the human trachea, Surg., Gynec. & Obst. ! 23:99, 1966. 81. Montgomery, W. W.: Reconstruction of the cervical trachea, Ann. Otol. 73:5, 1964. 82. Montgomery, W. W.: Cricoarytenoid arthrodesis, Ann. Otol. 75:3/';0, 1966. 83. Montgomery, W. W.: The surgical management of supragiottic and subglottic stenosis, Ann. Otol. 77: 534, 1968. 84. Mulder, D. S., and Rubush, J. L.: Complications of tracheostomy: Relationship to long term ventilatory assistance, J. Trauma 9:389, 1969. 85. Mulliken, J., and Grillo, H. C.: The limits of tracheal resection with prtmary anastomosis. Further anatomical studies in man, J. Thoracic & Cardiovas. Surg. 55:418, 1968. 86. Murphy, D. A., MacLean, L. D., and Dobeil, A. R. C.: Tracheal stenosis as a complication of tracheostom~, Ann. Thoracic Surg. 2:44. 1966. 87. Naef, A. P.: Extensive tracheal resection and tracheobronchial reconstruction, Ann. Thoracic Surg. 8:391, 1969. 88. Narodick, B. G., Worman, L. W., and Pemberton, A. H.: Relaxation technique for tracheal reconstruction, Ann. Thoracic Surg. I :190, 1965. 89. Ogura, J. H., and Powers, W. E.: Functional restitution of traumatic stenosis of the larynx and pharynx, Laryngoscope 74: 1081, 1964. 90. Pacheco, C. R., Rivero, O., and Porter, J. K.: Experimental reconstructive surgery of the trachea, J. Thoracic Surg. 27:554, 1954. 91. Pearson, F. G.: Personal communication. 92. Pearson, F. G., Goldberg, M., and da Silva, A. J.: A prospective study of tracheal injury complicating tracheostomy with a cuffed tube, Ann. Otol. 77: 867, 1968. 93. Pearson, F. G., Goldberg, M., and da Silva, A. J.: Tracheal stenosis complicating tracheostomy with cuffed tubes. Clinical experience and observations from a prospective study, Arch. Surg. 97:380, 1968. 94. Perelman, M., and Korolyova, N.: Surgery of tumours in the thoracic portion of the trachea, Thorax 23:307, 1968. 95. Petrovsky, B., Perelman, M'., and Kuzmichev, A.: Resection attd Plastic Surgery o/ Bronchi (Moscow: Mir Publishers, 1968). 96. Provan, J. L., and Austen, W. G.: The role of elective tracheostomy after open-heart surgery, Ann. Thoracic Surg. 2:358, 1966. 58

97. 98. 99. 100. 101. 102. 103. 104. 105. 106. 107. 108. 109. 110. 111.

Ranke, E. J., Presley, S. S., and Holinger, P. H.: Tracheogenic carcinomas. J.A.M.A. 182:519, 1962. Rob, C. G., and Batcman, G. H.: Reconstruction of the trachea and cervical esophagus, Brit. J. Surg. 37:202, 1949. Sara, C.: Histologic~ll changes in the trache~t and bronchi with trachcostom),, M. J. Austr~dia 1 : 1 ! 74, 1967. Senyszyn, J. J., and Jacox, 1t. W.: Primary carcinoma of the trachea followcd by primary carcinoma:! of the esophagus after a six-year interval. Radiology 92: 1346, 1969. Shaw, R. R., Aslami, A., and Webb, W. R.: Circumferenti~l replacement of the trachea in experimental animals, Ann. Ttioracic Surg. 5:30, 1968. Shaw, R. R., Paulson, D. L., and Kee, J. C., Jr.: Traumatic tr't~cheal rup{tire, J. Thoracic Surg. 42:281, 1961. Shelly, W. M., Dawson, R. C., and M,~y, I. A.: Cuffed tubes as n cause of tracheal stenosis, J. Thoracic & C:lrdiovas. Surg. 57:623, 1969. Silen, W., and Spiekcr, D.: Fatal iaemorrhage from the innominate ~lrtery after tracheostomy, Ann. Surg. 162: 1005, 1965. Sisson, G. A., Straehley, C. J., Jr., and Johnson, N. E.: Mediastinal dissection for recurrent cancer after laryngectomy, l_~ryngoscope 72: 1064, 1962. Sore, M. L., and Klein, S. H.: Primary anastomosis of the trachea after resection of a wide segment: An experimental study, J. Nit. Sinai Hosp. 25:211, 1958. Spinazzola, A. J., Graziano, J. L., and Neville, W. E.: Experimental reconstruction of the tracheal carina, J. Thoracic & Cardiovz~s. Surg. 58:i, 1969. Stiles, P. J.: Tracheal lesions after tr;~cheostomy, Thorax 20:517, 1965. Waddell, W. R., and Cannon, B.: Technic for surgical excision of trachea and establishment of sternal tracheostomy, Ann. Surg. 149: 1, 1959. W~Jlts, J. McK.: Tr~lcheostomy in modern practice, Brit. J. Surg. 50:954, 1963. Yamasigawa, E., and Kirchner, J. A.: The cuffed tracheotomy tube, Arch. Otolaryng. 79:80, 1964.

59