J THORAC CARDIOVASC SURG 78:860-875, 1979
Surgical treatment of postintubation tracheal injuries Two hundred-eight patients underwent tracheal resection and reconstruction for postintubation injuries from 1965 to early 1979. All but seven had received ventilatory assistance. Thirty-three had undergone prior attempts at surgical reconstruction. Twenty-three had had endotracheal tubes only. The patients had 112 cuff lesions. 78 stomal. 13 at both levels. and four lesions of uncertain origin. One hundred ninety-four had stenosis with or without accompanying malacic change. four showed "pure" malacia. nine had tracheoesophageal fistulas. and one had a tracheoinnominate fistula. There lI'ere many laryngeal injuries; 25 (if these lI'ere major injuries to the loll' subglottic larynx. necessitating partial or complete removal of the anterior cricoid cartilage. Two hundred sixteen reconstructions lI'ere done. eight for restenosis after initial resection. Cervical approach lI'as used in 126. cervicomediastinal in 83. transthoracic in six. and cutaneous reconstruction in one. The length of resection extended to 7 cm . Techniques for obtaining tension-free anastomosis included cervical flexion in all. laryngeal release in 20. hilar release in two. and use of partial external splinting in four. Fifty-seven required laryngotracheal anastomosis and nine partial laryngoplasty. Concurrent tracheostomy lI'as rare except in the last group. One hundred-two open stomas lI'ere variously managed. There lI'erefive deaths (2%)-only one in a truly elective patient. Nine failures (5%) occurred. Ninety-three percent (189 patients) showed good (168) or satisfactory (21) results. Granulations at the suture line. necessitating bronchoscopy. lI'ere the most common complication. noll' seemingly avoided by use of absorbable sutures. Only one patient had postoperative innominate arterial hemorrhage.
Hermes C. Grillo, M.D., Boston. Mass.
T
he lesions produced in the trachea by the erosive or cicatricial response to injury by intubation have in recent years provided the most common indication for tracheal resection and reconstruction. The period spanned in this report, from January, 1965, to early 1979-just a little over 14 years-saw the rapid evolution of more aggressive and effective techniques for the surgical management of tracheal lesions by primary resection and anastomosis. 1-3 From Jan. 7,1965, to Feb. 22,1979,208 patients were subjected to tracheal resection and reconstruction for postintubation lesions of the trachea. This report considers only this group of patients. The field for tracheal reconstructive surgery is well described by the comparative fact that during a slightly longer period From the General Thoracic Surgical Unit, Massachusetts General Hospital, and the Department of Surgery, Harvard Medical School, Boston, Mass. Read at the Fifty-ninth Annual Meeting of The American Association for Thoracic Surgery, Boston, Mass., April 30 to May 2, 1979. Address for reprints: Dr. Hermes C. Grillo, Massachusetts General Hospital, Boston, Mass. 02114.
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only 41 patients with primary and secondary tumors of the trachea underwent primary resection and reconstruction of the trachea at the Massachusetts General Hospital. ~ Twenty-two additional patients underwent tracheal resection and reconstruction for benign stenosis from other causes: trauma, 10; postoperative stenosis, four; congenital disease, two; post-burn stenosis, two; tuberculous stenosis, one; stenosis following foreign body trauma, one; and idiopathic stenosis, two. These 22 cases of benign stricture have been omitted from the present report to preserve the homogeneity of the group. Selection of patients The generally poor response to conservative measures for the treatment of postintubation tracheal stenosis, extensive either in length or in depth of injury to the tracheal wall, led me to adopt resectional treatment as the approach of choice. 5 Success has been reported with various techniques, including prolonged stenting, repeated dilatations, local use of steroids and other medications, and other physical modalities for the de-
0022-5223/79/120860+ 16$01.60/0 © 1979 The C. V. Mosby Co.
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Fig. I. Tracheal reconstruction in a patient with poor respiratory function. The patient was 50 years old and had undergone a thoracoplasty for tuberculosis in 1950. He was a cigarette smoker until age 40. Three episodes of respiratory failure required ventilation. Forced expiratory volume in one second, 0.93 L (25% of predicted). Vital capacity, 2.2 L. Peak flow, 88 Llmin (15% of predicted). Maximum breathing capacity, 37 L (24% of predicted). Paco" 49 mm Hg. A. The glottic aperture is seen at the very top of the roentgenogram. The stenotic segment is marked at upper and lower ends by arrows. B. Postoperative roentgenogram showing normal appearing lumen. Arrow marks anastomotic site. Note devolution of glottic level.
struction of scar tissue (including biopsy forceps, electrocoagulation, cryosurgery, and laser techniques). However, these generally have provided satisfactory results only in lesser degrees of tracheal destruction. Resectional treatment was withheld during the period of this study only in those patients whose medical condition was too poor to permit operation, in those whose disease contraindicated an attempt at reconstruction, or in those in whom the extent of tracheal destruction was so great that insufficient normal tissue remained to allow successful reconstruction. Since most patients can tolerate the extrapleural, mediastinal approach, minimal pulmonary reserve alone was not considered to be reason for rejecting operating (Fig. I). Diseases such as myasthenia gravis with frequent exacerbations which would predictably necessitate tracheostomy again in a short period of time or quadriplegia in a patient who would be unable to control secretions without the benefit of a tracheostomy were considered to be contraindications. Six quadriplegic patients did successfully undergo tracheal reconstruction. Repair was also avoided in those patients who were still supported by respirators or who were considered almost certain to require respiratory support postoperatively, unless no alternative was possible. The total number rejected for operation was small.
Composition of the series The 208 patients were divided almost equally into 103 males and 105 females. The causes of the postintubation stenosis included all of those diseases which result in respiratory failure, 6. 7 but the group also included seven patients who had tracheostomy for varying reasons but had never been placed on a ventilator. Age distribution was as follows: 10 to 14 years, three patients; 15 to 19 years, 28; 20 to 39 years, 33; 30 to 39 years, 27; 40 to 49 years, 31; 50 to 59 years, 32; 60 to 69 years, 37; and 70 to 79 years, 16 patients. In 33 of the 208 patients the original treatment which resulted in the stenosis was performed at the Massachusetts General Hospital. The remaining 175 were referred specifically for definitive treatment of their tracheal lesions. Most patients, particularly in the earlier years of the study, had undergone numerous attempts at conservative management often over long periods of timesometimes years-prior to referral. These treatments included bronchoscopic dilatations and removal of granulation tissue, local injection and topical application of steroids, cryosurgery and other physical modalities of tissue destruction, and tracheostomy with stenting by various types of tracheostomy tubes. Operative approaches had included prior resection in 20 patients. Another 13 had undergone significant surgical
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Fig. 2. Diagram of principal postintubation lesions. A, Lesion at cuff site in a patient who has been treated with an endotracheal tube alone. The lesion is high in the trachea and is circumferential. B, Lesions which occur with tracheostomy tubes. At the stomal level, anterolateral stenosis is seen. At the cuff level, lower than with an endotracheal tube, circumferential cuff stenosis occurs. The segment between is often inflamed and malacic. C, Damage to the subglottic larynx. A high tracheostomy or one which erodes back by virtue of the patient's anatomy may damage the inferior cricoid and produce a low subglottic stenosis as well as an upper tracheal injury. D, Tracheo-esophageal fistula (TEF). The level of fistulization is usually where the cuff has eroded posteriorly. Occasionally, angulationof the tip of the tube may produce erosion from the tip. There is also usually severe circumferential damage at this level by the cuff. E, Tracheoinnominate fistula (TlF). A high-pressure cuff frequently rests on the trachea directly behind the innominate artery. Erosion may occur, although rarely. The more common innominate artery injury is from a low tracheostomy where the inner portion of the curve of the tube rests in proximity to the artery and causes direct erosion. approaches including five who were treated with local plastic procedures and T-tube insertion, four in whom Marlex or Tantalum mesh had been utilized for repair, two who had undergone surgical treatment of tracheoesophageal fistula (one by dermal grafting and the other by colon bypass), two who had had several stages of a skin trough reconstruction performed, and one who had undergone hyoid bone grafting for low subglottic stenosis. In two, innominate artery hemorrhage had been controlled by ligation of that artery. Several had had laryngeal releases performed during their prior surgical repairs.
Diagnosis The diagnostic study of these patients has been well described." 9 This included as detailed historical information about the origin of the lesion as could be obtained, bacteriologic study of tracheal secretions and stoma, if present, and careful radiologic appraisal of the location and extent of the lesion as well as the
amount of normal trachea remaining. 7. 10 Most important is a precise evaluation of the functional status of the larynx, since many of these patients had endotracheal intubation, high tracheostomies, or even cricothyroidotomies which had resulted in laryngeal injury also.
Lesions In 23 patients the lesions resulted primarily from the use of endotracheal tubes for ventilation (Table I). Twenty-two of these 23 patients appeared to have sustained lesions caused by pressure necrosis by the cuff on the endotracheal tube. Cuff lesions from endotracheal tubes tend to be higher in the trachea than those from tracheostomies because of the usual location of the cuff (Fig. 2). The full thickness of the tracheal wall was often not destroyed, so that residual cartilage was present. This is probably related to the relatively brief exposure of patients to endotracheal tubes as compared to tracheostomy tubes. In one of the 23 patients the
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Fig. 3. "Pure" tracheal malacia owing to cuff injury. A, At rest, little irregularity may be seen in the tracheal air column. B, With cough and forced breathing, collapse occurs at the level of tracheal softening. In this case the segment had been producedby cuff level destruction of the tracheal cartilages.
Table I. Postintubation tracheal injury Endotracheal tube only Tracheostomy Cuff Stoma Both Uncertain Total
23 185
90 78 13 4 208
lesion most probably was the result of cricoid damage by an endotracheal tube. In patients who had received their treatment in other institutions, it was often difficult to be absolutely certain about the vicissitudes of their courses prior to transfer. Several of these patients also had been treated by tracheostomy prior to referral, which made the injury more complex. In two patients severe subglottic laryngeal injuries appeared to have resulted from tracheostomy. Exposure to the endotracheal tube was surprisingly short in many of the cases. In one the exposure was less than 18 hours, in one less than 36 hours, and in several less than 48 hours. One hundred eighty-five patients presented with lesions which followed the use of tracheostomy tubes. Of the seven who had never used a ventilator, two had had tracheostomy tubes with cuffs for protection from aspiration following radical neck and jaw operations, one following a severe inhalation burn, one for laryngeal
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Fig. 4. Complex of post-tracheostomy lesions necessitating lengthyresection. A, Preoperative roentgenogram. The upper arrow marks the glottic level. The central arrow represents the point where the trachea becomes diseased just above a large chronic stoma. Below this the trachea narrows and is malacic, with an area of stenosis at the lower end which has been held apart by an inlying tracheostomy tube. The lower arrow marks the approximate lower limit of severe injury. The lowermost marker is just below the carinal spur. B, Postoperative view. The upper arrow demonstrates the new level of the glottis. It must be noted that approximately 2 ern of subglotticairway is intralaryngeal. The carina is marked as in the preoperative roentgenogram. A 7 em portion of the trachea was resected in this patient.
edema of uncertain origin related to alcoholism, one following severe neck laceration, one for diphtheria in childhood with subsequent attempts at repair, and one for bilateral recurrent nerve palsy following a thyroid operation. All but one of these patients were referred. Identification of the precise origin of the lesion is not always easy. With multiple attempts at treatment and often multiple tracheostomies, the original lesion becomes lost in the evolution. As best as could be determined, the origin of the postintubation lesions was as follows: lesions resulting from cuff trauma, 112; stomal lesions, 78; lesions at both cuff and stomal levels, 13; and lesions of uncertain origin, either from cuff or stoma or confluence of both, four. The 112 cuff lesions include those originating from endotracheal tubes as well as from tracheostomy tubes. In recent years the number of cuff lesions has declined because of the introduction of large-volume, low-pressure cuffs. At
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Massachusetts General Hospital, there have been no instances of cuff stenosis resulting from the use of a compliant and extensible, large-volume, latex cuff. It The widespread introduction of large-volume cuffs constructed from plastic materials also has significantly reduced the number of stenoses. Lesions still occur when the relatively inextensible plastic cuffs are inflated beyond their resting maximal volume and thereby are converted to high-pressure cuffs. Despite the understanding that stomal lesions probably result from leverage of equipment against stoma, a small number of such lesions continue to occur, particularly in the older patient in whom anatomic factors predispose to such injury. Thus the number of stomal lesions repaired surgically has been slowly catching up with those of cuff origin. When the full thickness of the tracheal wall has been damaged so that cartilages are no longer present in the area of injury, an additional quality of malacia may be present. This condition permits the segment to collapse with increased respiratory effort and coughing. In some cases such a segment may present as malacia only. Thus a resting roentgenogram may show little, if any narrowing at the level of the lesion, but a dynamic study demonstrates it to valve and close completely with coughing and maximal respiratory effort (Fig. 3). Two such lesions which could be characterized as pure malacia were seen at cuff level, one at stomal level, and one in a patient who had extensive injury judged to be the result of confluent stomal and cuff injury. In a number of patients there was also an associated malacic change in the segment of trachea between the stoma and a stenotic cuff lesion (Figs. 2 and 4). In one there was softening associated with a small recurrent thyroid adenoma adjacent to a prior area of stomal injury. The identification of such areas of malacia was enormously helped by careful fluoroscopic study of the trachea under dynamic stress. The surgeon should see the fluoroscopic examination or a videotape of it. A simultaneous careful study of laryngeal function is also necessary. Tracheoesophageal fistula was present in nine patients (Fig. 2). In eight of these the lesion clearly originated from erosion by a tracheostomy tube cuff. In two of the eight the tracheal damage, however, extended up to the stoma, although the fistula itself was related to the cuff. In one there was a residual fistula related to an erosion by a cervical bone graft. This lesion lay adjacent to a stomal stenosis. One patient presented with a trachea-innominate artery fistula from direct erosion of a high-pressure cuff through the anterior wall of the trachea into the innomi-
Thoracic and Cardiovascular Surgery
nate artery (Fig. 2). During the period of this study an additional patient with a tracheoinnominate fistula caused by erosion of the artery by the tube at the lower margin of the stoma was treated successfully by arterial excision. This patient is not included in this report since the trachea itself in this circumstance requires no treatment. The lesion is arterial. Laryngeal injury was very common. Most patients had undergone periods of endotracheal intubation. Laryngeal polyps, vocal cord thickening, and posterior glottic commissural stenosis were seen. Low subglottic injury was relatively common, presenting as narrowing of the subglottic larynx by submucosal fibrosis and as erosion of the lower margin of the cricoid cartilage by impingement of a tracheostomy tube. The latter was frequently seen in the elderly, kyphotic patient in whom there was little distance between the cricoid cartilage and sternum. In 25 patients there was major encroachment on the cricoid cartilage with stenosis extending into the lower larynx and with destruction of the anterior cartilage. In a total of 48 it was necessary to bevel the lower portion of the cricoid cartilage, for both major and minor encroachment, in order to perform laryngotracheal anastomosis. In nine patients the injury to the larynx was so severe that the low, anterior larynx had to be resected and an anastomosis made anteriorly to the thyroid cartilage. In two patients laryngeal disease was such that it was necessary first for a consultant otolaryngologist to correct glottic anatomy and function before a tracheal repair could be done safely. This is always the proper sequence of events. It is impossible to correct a tracheal lesion or even a low subglottic lesion successfully without an adequate glottis. In several patients there was a pre-existent cord palsy or partial malfunction of a vocal cord or cords. Cricothyroidotomy had been done previously in three patients and in two had made a major contribution to the obstructive airway disease. Operative treatment
Two hundred sixteen resections and reconstructions were performed in this group of 208 patients. Eight of the patients suffered restenosis following the initial procedure were reoperated upon at a later date. Two of the 208 patients suffered failure of their initial operation, and this was corrected in a second procedure done within hours of the initial operation. These are therefore not counted as additional reconstructions. During the period of this study four patients with tracheal stenoses had exploratory operations because their lesions appeared to be of borderline potential for repair. One had undergone two reconstructions elsewhere and
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Fig. 5. Tomographicdetail of extensive tracheal lesion. A. Anteroposteriorview. The arrows mark the upper and lower limits of disease. The glottic apex may be seen above with the shadow of the thyroid cartilages laterally. The bell shape of the upper airway represents intralaryngeal airway. Only one ring of trachea remains intact above. The area of lucency above the lower arrow representsa stoma below this lengthy stenosis with destruction at that level as well. B. Lateral view. In planning for resection it is necessary to encompass even the partially narrowedtrachea and to transect where the tissues are as close to normal as possible. The stomal tract may also be seen. In this patient. a young female, 60% of the trachea was resected with only a cervical approach. Mobility and extensibility of the trachea permitted this. another, one reconstruction. One had had multiple attempts at intubation splintings. In all three cases the lesions were deemed to be unreconstructible by primary anastomsis and were treated by placement of Montgomery silicone rubber T-tubes. 12 A fourth patient died during exploration prior to resection at the inception of the series. One patient suffered restenosis after resection of a prior fabric repair. At re-exploration the lesion was found to be unreconstructible. He was also treated with aT-tube. The techniques of anesthesia have been described. 13 I believe that these patients should be maintained on spontaneous respiration and that the anesthesia should be conducted so that they will breathe spontaneously following completion of the procedure without need for respiratory assistance. Cardiopulmonary bypass has been wholly unnecessary. As experience has grown, bronchoscopy has been performed at the time of resection in all but those patients whose lesions seemed unlikely to be reconstructible. If the airway is 5 mm in diameter or less, dilatation is done initially under general anesthesia using pediatric bronchoscopes serially. This prevents accretion of carbon dioxide with its hazard of arrhythmia. If the lumen is greater than 6 mm
Table II. Operative approach Cervical Cervicomediastinal Transthoracic Cutaneous tube
126 83 6
Total
216
1
in diameter, intubation is carried out above the lesion and dissection done delicately so that the airway will not be obstructed. When a stoma is present the anesthesia is often induced through this route. Surgical techniques of approach and reconstruction have been adequately described.?: 14 In this series the cervical approach was sufficient in 126 patients (Table II). In 83 a partial upper sternal division through the sternal angle was utilized. In six a transthoracic approach was used, either by a cervicothoracic incision or a high posterolateral thoracotomy with a complementary cervical approach, if needed. As experience has increased, it has become clear that most postintubation lesions may be approached from an anterior cervical or cervicomediastinal route. Thus two more recent patients have undergone cervicomediastinal re-
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Fig. 6. Methods for obtaining tracheal approximation. A, Lateral neck view. The hyoid bone and epiglottis are clearly visible beneath the angle of the mandible. The density of false and true cords with the ventricle between are noted below. There is calcification of the thyroid and cricoid cartilages. B, Following an extensive resection of more than 50% of this patient's trachea, approximation has been achieved by flexion of the cervicalspine with devolvement of the tracheainto the mediastinum. In addition, a suprahyoid laryngeal release has been done. The two black arrows beneath the mandible show the surgical divisionof the anteriorhyoid and its releasedownward for a distance of about 1.5 em. The white arrow shows the new level of the laryngeal ventricle just above the sternal density. The cervical trachea has thus become mediastinal. section of immediately supracarinal lesions. These patients were managed anesthetically with tubes alternately in the right and left main bronchi. In only three of the six patients operated upon transthoracically would that approach now be employed. These include one patient who had a prior transthoracic supracarinal resection elsewhere with placement of a Marlex patch; one who had undergone transthoracic approach and resection of a supracarinal stricture, with hilar mobilization; and a third patient who had an anomalous right tracheal bronchus to a portion of the right upper lobe. In the remaining three the lesion would clearly be accessible from the anterior approach. The anterior approach has much less physiological impact on patients with limited pulmonary reserve. One patient early in the series who had had multiple attempts at correction of tracheal stenosis elsewhere, had severe asthma which precluded transthoracic approach. He underwent staged reconstruction to fashion a full-thickness cutaneous tube to connect the larynx to the residual trachea. This procedure has not been proposed for other patients with benign stenotic lesions involving very long segments of trachea because of the complexity of the repair and the possibilities for dangerous complications. Such patients have been preferentially managed by the placement of T-tubes, as noted earlier. The amount of trachea resected varied as follows: 0 to 2 cm, 41 patients; >2 to 4 em, 145; >4 to 6 em, 28;
and >6 to 7 cm, 2 patients. In the majority of patients sufficient length was obtained for approximation without tension by freeing only the anterior surface of the trachea from the cricoid to the carina with great care being given to preservation of the lateral blood supply. The importance of not devascularizing residual trachea cannot be overstressed. 15, 16 The length of trachea which may be resected and approximated by flexion varies greatly with the age and build of the patient and the residue from prior operation (Fig. 5), Where tentative flexion did not indicate that approximation could easily be obtained, laryngeal release proved to be a useful adjunct (Fig. 6). In nine patients the thyrohyoid release technique described by Dedo and Fishrnan " was utilized. Because of the occurrence of postoperative dysphagia, sometimes prolonged, despite great care not to injure the superior laryngeal nerves, this technique of release was replaced with the suprahyoid technique of Montgomery. 18 This was employed in 11 patients, Transient dysphagia was seen in some of these patients, but it was less severe, was of short duration, and was accompanied by little, if any, aspiration. Of these 216 patients, 148 underwent trachea-totrachea anastomosis (Fig. 7). Selection of the levels of resection and anastomosis is a critical matter but it cannot be easily described. The trachea distal to stenosis is often relatively normal. Proximal to a cuff stricture, varying degrees of injury to the trachea are frequently
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seen, including submucosal fibrosis and, sometimes, the malacia previously described. Proximal to a stomal stenosis chronic inflammation of the larynx is often present, sometimes with permanent submucosal narrowing and partial stenosis. Experience permits the surgeon to determine where the transection may be done safely, Removal of insufficient amounts of trachea may lead to prompt recurrence of stenosis. It is insufficient for only one side of the anastomosis to be adequate. On the other hand, it is often impossible to find completely normal airway proximal to the principal injury. In general there must be good cartilaginous structure present and as little inflammation as possible. It is preferable where possible to save at least one ring below the cricoid or even one half ring. This permits a nondiscrepant anastomosis. However, compromise must not be made with inadequate tissue. Fifty-seven patients underwent laryngotracheal anastomosis, the trachea being sutured to the cricoid cartilage. Varying amounts of the anterior cricoid were beveled off to provide good tissue and, also, an adequate proximal lumen. Frequently there is a shelf of low subglottic stricture anteriorly at the lowermost portion of the larynx just above a high, eroded stoma. This can be determined at operation by careful probing and examination. In nine patients the stenosis extended well into the subglottic larynx. In these patients it was necessary also to correct the laryngeal stricture, since the airway was inadequate if transection was done at the lower border of the cricoid. Since most of these were stomal injuries, the posterior cricoid plate was generally intact. The anterior portion of the larynx was resected to the inferior margin of the thyroid cartilage in a sloping line which preserved the posterior cricoid plate with its closely attendant recurrent laryngeal nerves. Distally, the trachea was beveled from front to back so that it fit into this anastomosis (Fig. 7). The technique used was somewhat different from that described by Pearson and his associates'? in that no attempt was made to groove the cricoid or to narrow the tracheal lumen. The one patient who underwent multistaged, fullthickness skin tube reconstruction with buried plastic ring supports has been noted. In only one patient, an anterior wedge resection was successfully done for a very limited anterolateral stomal stenosis. Another attempt at wedge resection produced a valving effect which necessitated completion of a circumferential resection a few hours later. Concurrent tracheostomy was used only in specific circumstances. In five of the nine patients who underwent anterior laryngeal resection in addition to tracheal
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B
c
Fig. 7. Diagram of categories of anastomoses. A, Tracheotracheal anastomosis. The simplest and least discrepant anastomosis is at any level in the trachea where even one half ring remains for the suture line. B. Laryngotracheal anastomosis. Here the distal trachea is anastomosed to the inferior margin of the cricoid cartilage. In many cases the inferior portion of the anterior cricoid cartilage is beveled off to improve the airway and remove anterior, low subglottic stenosis extending to this level. C, Laryngoplasty tracheal anastomosis. In cases in which the subglottic stenosis extended above the upper border of the cricoid cartilage anteriorly on in which the anterior cricoid was destroyed by erosion from a stoma, the anterior portion of the cricoid cartilage was resected, usually including the cricothyroid membrane, to the inferior margin of the thyroid cartilage. The posterior cricoid plate was carefully saved. The trachea is appropriately tailored to fit this complex anastomosis.
resection, a small tracheostomy was placed, a mirumum of two rings and preferably further below the level of anastomosis. The anastomosis was walled off. Tracheostomy immediately adjacent to an anastomosis will cause injury and restenosis. Tracheostomy through an anastomotic line is absolutely to be avoided. In four of the patients who underwent laryngeal reconstruction, the extent of resection and the retromanubrial placement of the larynx did not permit tracheostomy. Varying periods of postoperative intubation were necessary before the laryngeal airway functioned properly. In one patient the tracheostomy tube was left in place for 2 months, whereas the other four patients were extubated prior to hospital discharge. Five patients who underwent laryngotracheal anastomosis without partial laryngeal resection had such tenuous airways, due to submucosal fibrosis of the larynx, that small tracheostomy tubes were also used for protection in the early postoperative edematous phase. One patient who had sustained airway bums required concomitant tracheostomy because of the poor condition of the proximal airway. An existing tracheal stoma was managed in various ways. One hundred two of the 208 patients presented with open stomas. In 68 the stoma was excised with the
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Fig. 8. Recapture of tracheal length by permitting the stoma to close. These sketches were made on exact tracings of x-rays films. The patient was an 18-year-old woman with a severe head injury who underwent multiple tracheostomies and prolonged periods of ventilation. A long distal stenosis developed. A large tracheostomy was made for emergency treatment of an acute episode of obstruction and the patient was referred with a tube in place. The first sketch shows the situation at the patient's arrival. There is a healed scar from a high stoma from a previous tracheostomy. The fresh stoma is shown immediatelyabove the lengthy low stenosis. Resection of the stenotic segment and the adjacent stoma. which would have been necessary had an operation been performed immediately, would have destroyed too much trachea for safe endto-end reconstruction. There was insufficient trachea intact beneath the stoma to permit anastomosis at that level. Therefore, the stoma was allowed to heal with repeated dilatations over a period of about 3 weeks. The second sketch shows the patient at that point. The large stoma has healed sufficiently so that that segment of trachea is now useful for repair. Therefore, the area of resection has been reduced by nearly 2 cm. The third sketch is from a tracing of the repaired trachea. specimen. In 17 it was allowed to remain in place, undissected, to heal at a later date. In two patients it was necessary to free the trachea from the overlying skin in order to slide the trachea distally toward the mediastinum. The stoma was then transplanted to another point. In two patients with long lesions and secondary stomas immediately adjacent, the tracheostomy was allowed to heal in order to preserve length for a
Thoracic and Cardiovascular Surgery
later reconstruction. Repeated dilatations of the stenosis were necessary during the waiting period (Fig. 8). In two patients who underwent anterior laryngeal resection, a lower existing tracheostomy was detached from the skin but then reimplanted and used as a complementary postoperative tracheostomy. An existing stoma was closed in seven patients by turning of a strap muscle flap, where the stoma would become retrosternal. In four additional patients tracheocutaneous epithelial healing was present at the time of operation, and a primary cutaneous inversion was used for closure of the stoma.P" The balance of the patients either had no stomas (since their lesions had resulted from endotracheal tubes without subsequent tracheostomy for treatment) or had healed stomas. Three patients in whom stomas were left to heal eventually required surgical closure. The anastomoses were performed with varying materials. The technique seemed to require strong but fine suture material. In the period 1965 to 1967, 4-0 Dacron was the principal suture material. From 1968 into 1978, 4-0 Tevdek was chiefly used. Prolene proved to be too extensible. More recently 4-0 Vicryl has been used in 20 patients. This absorbable material is more difficult to use because of its friction but was employed to try to reduce the incidence of granulomas. The management of tracheoesophageal fistulas resulting from intubation has been reported. 21 There were two other associated esophageal lesions. One patient had a large Zenker diverticulum excised at the time of tracheal repair. Another patient had an esophageal stenosis of uncertain origin at the same level as the tracheal stenosis. Segmental esophageal resection and anastomosis was completed at the same time as the tracheal repair. One patient in the series had a carinal resection and reconstruction done as a method of managing an already shortened trachea in which a previous Marlex repair had been performed. One other patient required extensive intrapericardial hilar mobilization as part of a repair where previous resection had been done transthoracically and restenosis had occurred. In the other patients such extensive mobilization, often needed in resection of tumors, was not required. Only a small number of patients were deemed to require protection of the innominate artery from an adjacent anastomotic line by rotation of a strap muscle flap, although more than 100 had resections in this region. Dissection was made scrupulously close to the trachea and skeletonization of the artery was avoided. In four patients distal cuff stenosis was accompanied by extensive proximal tracheomalacia. In each of these
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B
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Fig. 9. Use of splinting rings in extensive, complex injuries. A, A 60-year-old patient with a malacic segment at stomal level very close to a stenotic segment at cuff level. The resection was limited by removing only the stenotic segment and splinting the proximal malacic segment with a polypropylene ring placed in a channel around the segment. B, A 16-year-old boy was found to have airway obstruction owing to a depressed anterior flap above a tracheostomy following resection of a distal cuff stenosis. Through an incision above the stoma, a ring was slipped around the trachea and the obstructing flap pulled out and held by the splinting ring. The stoma was allowed to close spontaneously. C, Subtotal tracheal destruction. A 47-year-old patient with chronic obstructive pulmonary disease with a long malacic segment encompassing an open chronic stoma. Only one ring below this level, there was a lengthy supracarinal stenosis. The patient could not be managed with a tracheostomy tube because of the proximity of the stenosis to the carina. The distal stenosis was resected, the stoma closed by the cutaneous inversion technique, and the lengthy segment splinted with two rings. This patient failed to survive. See text. D, A 53-year-old man with a proximal malacic segment at stomal level and a distal cuff stenosis. Although there were several rings in the intact segment between the upper and lower lesions, the length was insufficient to be certain that the blood supply would remain intact if dual resections were done simultaneously. Therefore, the stenosis was resected and the upper segment splinted, as shown. Patients A, B, and D did not require removal of the rings over periods of 7, 9, and 3 years of follow-up.
patients resection to include the malacic segment would have been too extensive for reconstruction. Short interval segments of relatively good cartilages might have been endangered in blood supply by dual concurrent resection. The problem was met by placing one or more polypropylene rings around the trachea for support'" (Fig. 9). The rings were placed in individual tissue channels so that they would be totally embedded in the patient's tissues. The anterior portion of the ring was further sealed with strap muscle. In three patients of this group who survived, there has been no difficulty over 3, 7, and 9 years. The postoperative stay for most patients was 7 to 14 days. Results
Postoperative roentgenograms of the trachea were obtained prior to discharge. Additional roentgenograms
were either obtained or requested at about 3 months and, as much as possible, at a later interval. Wide geographical distribution of the patients has made personal follow-up difficult, but patients and physicians have been contacted by mail and telephone as a second best alternative. The results have been classified as good, satisfactory, failure, and death. The result is described as "good" if the patient is functionally able to perform all his usual activities and if postoperative roentgenograms or bronchoscopic examinations show an anatomically good airway, with only minimal narrowing of the anastomosis. Patients are placed in the "satisfactory" category if they can perform their normal activities but are stressed on exercise, if they have abnormalities such as a paralyzed or partially paralyzed vocal cord, and if there is significant narrowing evident on either endoscopic or roentgenologic examination,
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Thoracic and Cardiovascular Surgery
Table III. Results of reconstruction
I
No.
, - -Percent -----
Good Satisfactory Failure Death
168
83 10 5 2
Total
203*
Result
21
9 5
"Incomplete follow-up, five patients.
even if the patient's level of activity does not clinically evidence this. "Failure" usually necessitated tracheostomy. Follow-up was not obtained beyond the early posthospital period in five patients. Of the remaining 203 patients, including 16 who were operated upon less than I year ago, 168 are categorized as having good results, 21 satisfactory, nine failures, and five deaths. Of the 16 patients who have been treated in the most recent period, 15 have no complications of any type and have good anatomic and physiological results. One patient has no complaints but has been demonstrated radiologically to have a partial palsy of one vocal cord which mayor may not be permanent. His condition is classified as "satisfactory." In percentages, the results are as follows: good 83%, satisfactory 10%, failure 5%, and dead 2% (Table III). Deaths. Five patients who underwent resection and reconstruction died postoperatively in the hospital. Four of these patients were in categories which contraindicated reconstruction. The urgency of their anatomic or medical situation required desperate attempts at salvage and in this sense the operations were considered to be obligatory. The first patient had undergone a cardiac operation in another city, had developed a low tracheal stenosis, and had undergone a transthoracic resection of the stenosis with the placement of a Marlex patch. The lower portion of this patch resided immediately above the carina, and scarring and granulations appeared at both ends of the Marlex patch. The patient was intubated and maintained on a respirator but had frequent episodes of respiratory arrest. When the tube would move a few millimeters above the lowermost portion of the stenosis at the carina, the airway would close beneath the tube and precipitate an arrest. This is one of the few situations in which a patient with tracheal stenosis cannot be maintained by dilatation of the stricture and tracheostomy. An attempt was made to correct the problem. Extensive transthoracic resection which required removal of the carina, mobilization of the lung, and a complex reconstruction
was performed. The patient required postoperative ventilation. Because of the shortness of the trachea the cuff necessarily remained close to the area of anastomosis, and within a short period of time separation occurred. The second patient had severe burns and a high-pressure cuff had caused erosion of the innominate artery, with cardiac arrest. The artery was resected and the damaged segment of trachea resected with endto-end anastomosis. During the cardiac arrest the patient had suffered brain injury and he remained comatose thereafter. He died with an intact trachea. The third patient in the "obligatory" group had had a traumatic rupture of the right main bronchus which was not recognized initially in another institution. The patient eventually underwent pneumonectomy and developed a stenosis of the lower trachea and, also, malacia of the left main bronchus from ventilation with a long tube passed beyond the low stenosis. The patient's airway remained unstable. She was transferred and the tracheal stenosis was resected. It was impossible to maintain the patient successfully with the malacic left main bronchus. The fourth patient had a combination of a long stomal malacic segment with an almost immediately adjacent supracarinal stenosis. The problem of repeated respiratory arrest despite the presence of a tracheostomy tube caused the patient to be transferred for an attempt at reconstruction. This was undertaken with recognition of the severity of the problem. The stenosis was removed, the stoma closed, and the proximal trachea splinted with plastic rings. The trachea became necrotic, a tracheoesophageal fistula resulted, and death ensued. One patient died after elective resection of a stenosis. She had had a previous Pseudomonas pneumonia which appeared to have regressed. Postoperatively she again developed bilateral Pseudomonas pneumonia which required ventilatory treatment for 2 weeks. However, she could not be weaned and ultimately the anastomosis gave way with hemorrhage from the innominate artery as the terminal event. During the period of this study two additional patients died who did not undergo resection. The first has already been mentioned. In a second patient an acute obstruction occurred during the induction phase prior to the time when a full battery of pediatric bronchoscopes was kept immediately at hand. Dilatation was attempted under acute circumstances but the patient died. Reoperations. Eight patients who underwent resection were reoperated upon for restenosis. One of them had undergone his initial resection at another institution and had suffered failure there as well as after his first
Volume 78 Number 6 December, 1979
operation here. One of the eight patients had originally had a cuff stenosis resected. He was known also to have some narrowing at the stomal site but it was hoped that this would not progress. It did stenose further and he required resection of this lesion as well. This proved to be successful. Of the other seven, five ultimately had good results and two satisfactory results. I have already mentioned the two patients who were noted a few hours postoperatively to have airway obstruction and had a further resection in the same day which led to a good result. Failures. The result of resection is classified as a failure in nine patients. One of the patients had severe neurologic injury including laryngeal malfunction on deglutition with aspiration. He had a relatively low stenosis and an operation was performed, probably inadvisedly. He continued to have aspiration following operation and ultimately died from pneumonia. A second patient had very severe heart disease and had cardiac decompensation postoperatively. She remained on a respirator for almost 2 months and, once weaned from the respirator, was found to have restenosis. A third patient had inadequate glottic function which was not appreciated on preoperative fluoroscopy and examination. Tracheal resection was anatomically successful but he required a permanent tracheostomy because of the glottic malfunction. The six additional patients in this group all suffered restenosis. One of them had had a tracheostomy initially for a burn of the airway, without ventilator support. This patient did poorly, as might now be anticipated. This is frequently the case when burn injury has occurred in the airway. The patient was ultimately treated with a T-tube with a satisfactory result but must be classified as a failure of tracheal reconstruction. Two of the remaining group underwent re-exploration with failure in each case. In one treated early in the series insufficient resection was performed and a malacic segment failed to function properly even after the second resection. The other patient had prior attempts at repair of the trachea before the first failure here. At the second operation the innominate artery was entered and had to be resected. The degree of damage of the trachea precluded reconstruction and aT-tube was placed. One patient had undergone previous reconstruction in another hospital. The reconstruction here failed and he required a permanent tracheostomy tube 3 years following the reconstruction here. A precipitating incident for the repeated tracheostomy was not clear. A final patient without prior operation had a similar fate. Complications. The complications experienced by those patients who died following tracheal reconstruc-
Postintubation tracheal injuries
87 1
tion and those in whom the operation failed have already been noted. The most common complication in the remaining 193 patients was the appearance of granulation tissue at the suture line. Those in whom the granulations became profuse and cicatricial and ultimately evolved to restenosis have been discussed as failures. Thirty-four of the 193 developed granulations. These required bronchoscopy for removal. Fifteen patients required one bronchoscopy; eight required two; six required three; three required four; one, five; one, six; and one, ten. The usual procedure was to remove the granulations with the biopsy forceps. Very often multiple nonabsorbable sutures were also plucked out. Triamcinalone was injected through a short ventilating tracheoscope directly into the base of the removed granulations in most. All 34 patients had nonabsorbable sutures used for anastomosis. No granulations have occurred thus far in the 20 patients who had anastomoses with absorbable Vicry I. An incidence of granulations of approximately one in six must be compared with zero in this recent group of 20 cases. Despite the presence of bacteria in all of the patients with open stomas and in many of those with incompletely epithelialized stenoses, wound infection was a relatively minor problem. Staphylococcus aureus and Pseudomonas aeruginosa were most commonly cultured from tracheal secretions. There were three cases of minor wound sepsis. Two other patients had infection in the sternum. Patients were generally managed with antibiotics given immediately before operation and for approximately 5 days postoperatively. The antibiotics were selected on the basis of cultures and sensitivities when available. One of the wound infections occurred in a patient who was operated upon without the benefit of antibiotics early in the series. This patient had normal flora and no open stoma. Two patients had partial separation of the upper sternotomies. These separations appeared to be more related to mechanical problems than to sepsis. Two patients developed an air leak in the first week which was easily managed in one with catheter suction for a few days and no treatment in the second. There were no sequellae. Although a significant incidence of innominate hemorrhage has been reported as a postoperative complication of operations for postintubation stenosis.F' only one such instance occurred in this series. Since a cuff stricture very frequently lies behind the innominate artery, we may conclude that at least 126 of these patients were potentially at risk and probably more. The principle of close dissection on the trachea, avoiding baring the artery of its surrounding scar tissue, has probably
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Thoracic and Cardiovascular Surgery
been the most important factor in avoiding this complication. Only rarely has tissue been interposed between the artery and the new suture line. In the patient who did have a leak from the innominate artery, the artery was successfully resected. However, this did lead to sepsis in the operative field with, ultimately, a partial separation of the anastomosis and, after healing, a partial stenosis and only a satisfactory result. Six patients experienced postoperative dysphagia of significant severity and persistence. In five this complication followed thyrohyoid release. Dysphagia cleared in weeks or months in all but a single exception. This patient has been able to function but has had difficulty with aspiration and dysphagia for several years. A sixth patient had dysphagia because of an approximately 50% resection of the trachea. The patient has learned to eat with the neck flexed to minimize the difficulty. Six patients were found to have either sluggish or paralyzed vocal cords unilaterally. Most of these patients did not have clinically significant complaints except for some hoarseness or weakness of voice. The findings were based on postoperative roentgenograms and fluoroscopy. In some cases the affection may have been present preoperatively since a complete assessment of laryngeal function was not done in every case prior to operation. A number of early postoperative complications were seen which were not notable. Several patients had intraoperative pneumothoraces during the cervicomediastinal approach. This was managed by aspiration or thoracotomy tube. Pulmonary embolism occurred in one patient. The same patient also developed Candida septicemia from a hyperalimentation line. This responded to amphotericin. Discussion With the exception of stenosis in the immediately supracarinal region, in which an airway can be maintained only with considerable hazard, and tracheoesophageal or tracheoinnominate fistulas, most postintubation lesions of the trachea can be managed conservatively by tracheostomy for indefinite periods of time. Although this will not lead to cure of any but the more superficial or minimal lesions, it does place a burden on the surgeon who proposes to treat the lesion by primary resection and anastomosis. The present series would seem to support an aggressive approach. Although the span of the series includes formative years of contemporary tracheal surgical approaches, the results of operation are largely favorable. Only one of five patients who died had a truly elective operation. Without attempting to minimize the failures, I can also
point out that of nine clear-cut failures, two were the result of reoperation in patients who had had previous reconstruction. Four probably represent errors in judgment in selection, in that one patient had an ineffective glottic aperture, the second required prolonged ventilation postoperatively, the third had neurologic glottic malfunction, and the fourth had a burned airway, a condition which heals notoriously poorly. An additional patient had an area of malacia which was not resected because of the failure to appreciate the need for such at that stage in surgical development. This left two difficult upper tracheal, low subglottic conditions that were also operated upon in the earlier years of the study. The difficulty of reoperation must also be emphasized. The best opportunity for surgical correction of tracheal disease is at the first procedure because of the small amount of available tissue in the trachea. A number of other reports on surgical treatment of postintubation stenosis support these conclusions. 24-26 REFERENCES I Grillo HC: The management of tracheal stenosis following assisted respiration. J THoRAc CARDIOVASC SURG 57:52-71, 1969 2 Grillo HC: Surgery of the trachea. CUff Probl Surg July, 1970 3 Grillo HC: Reconstruction of the trachea. Thorax 28: 667-69, 1973 4 Grillo HC: Tracheal tumors. Surgical management. Ann Thorac Surg 26: 112-125, 1978 5 Grillo HC: Management of tracheal stenosis. Resection and end-to-end anastomosis, Controversy in Otolaryngology, JB Snow Jr, ed., Philadelphia, W. B. Saunders Company (in press) 6 Andrews MJ, Pearson FG: Incidence and pathogenesis of tracheal injury following cuffed tube tracheostomy with assisted ventilation. Ann Surg 173:249-263, 1971 7 Weber AL, Grillo HC: Tracheal stenosis. An analysis of 151 cases. Radiol Clin North Am 16:291-308, 1978 8 Andrews MJ, Pearson FG: An analysis of 59 cases of tracheal stenosis following tracheostomy with cuffed tube and assisted ventilation, with special reference to diagnosis and treatment. Br J Surg 60:208-212, 1973 9 Grillo HC: Congenital lesions, neoplasms and injuries of the trachea, Gibbon's Surgery of the Chest, DC Sabiston Jr. FC Spencer, eds., Philadelphia, 1976, W. B. Saunders Company, p 256 10 MacMillan AS, James AE, Stitik FP, Grillo HC: Radiological evaluation of post-tracheostomy lesions. Thorax 26:696-703, 1971 II Grillo HC, Cooper JD, Geffin B, Pontoppidan H: A low-pressure cuff for tracheostomy tubes to minimize tracheal injury. J THoRAc CARDIOVASC SURG 62:898-907, 1971 12 Montgomery WW: The surgical management of supra-
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glottic and subglottic stenosis. Ann Otol Rhinol Laryngol 77:534-546, 1968 13 Geffin B, Bland 1, Grillo HC: Anesthetic management of tracheal resection and reconstruction. Anesth Analg 48:884-894, 1969 14 Grillo HC: Surgery of the trachea, Operative Surgery and Management, G Keen, ed., Bristol, John Wright and Sons (in press) 15 Grillo HC: Tracheal blood supply. Ann Thorac Surg 24:99, 1977 16 Salassa 1R, Pearson B, Payne WS: Gross and microscopic blood supply of the trachea. Ann Thorac Surg 23: 100107, 1977 17 Dedo HH, Fishman NH: Laryngeal release release and sleeve resection for tracheal stenosis. Ann Otol Rhinol Laryngol 78:285-296, 1969 18 Montgomery WW: Suprahyoid release for tracheal stenosis. Arch Otolaryngol 99:255-260, 1974 19 Pearson FG, Cooper 10, Nelems 1M, Vannostrand AWP: Primary tracheal anastomosis after resection of cricoid cartilage with preservation of recurrent laryngeal nerves. 1 THoRAc CARDIOVASC SURG 70:806-816, 1975 20 Lawson OW, Grillo HC: Closure of persistent tracheal stomas. Surg Gynecol Obstet 130:995-996, 1970 21 Grillo HC, Moncure AC, McEnany MT: Repair of inflammatory tracheoesophageal fistula. Ann Thorac Surg 22: 112-119, 1976 22 Grillo HC: Circumferential resection and reconstruction of mediastinal and cervical trachea. Ann Surg 162:374388, 1965 23 Grillo HC: Complications of tracheal operations, Complications of Cardiothoracic Surgery. AR Cordell, RG Ellison, eds., Boston, 1979, Little, Brown & Company 24 Dor V, Kreitmann P, Arnaud A, et al: Resection etendue de la trachee pour tumeur et stenose. Presse Med 79:1843-1846, 1971 25 Pearson FG, Andrews M1: Detection and management of tracheal stenosis following cuffed tube tracheostomy. Ann Thorac Surg 12:359-374, 1971 26 Webb WR, Ozdemir lA, Ikins PM, Parker FB 1r: Surgical management of tracheal stenosis. Ann Surg 179:819-824, 1974
Discussion DR. F. GRIFFITH PEARSON Toronto. Ontario. Canada
On those occasions during the past 15 years when Dr. Grillo has presented his own extensive and updated experience, we have been prompted to rethink and update our own. Our Toronto experience is about half of that seen by Dr. Grillo, but the composition, approach to management, and the results appear like those of a smaller, but identical twin. Between 1962 and 1979 at Toronto General Hospital, 129 patients have required segmental resection of the trachea. Eighty-seven of these patients had postintubation or posttracheostomy strictures, 27 had for primary tumors of the
Postintubation tracheal injuries
873
trachea, and seven patients required resection and reconstruction following various forms of trauma. In the 87 postintubation strictures, the distribution of level of injury was similar to that reported by Dr. Grillo. There were four operative or postoperative deaths, six instances of restenosis necessitating a second resection, and four cases of partial restenosis but a satisfactory or safe airway. Wound infection, which occurred in 10 of the 87 patients, was the complication most commonly followed by restenosis. I wished to complement Dr. Grillo's paper by defining a special group of patients in whom the silicone rubber Montgomery T-tube was used as an adjunct to resection and reconstruction. Dr. Grillo, I believe, has had a similar experience with this T-tube, but did not have the opportunity today to present this information. The Montgomery T-tube was developed by an otolaryngologist colleague of Dr. Grillo's at the Massachusetts Eye and Ear Infirmary. It is a soft, pliable, hollow, silicone rubber cylinder with a smaller T-arm. The silicone cylinder lies within the airway and can be used to stent or support a tracheal anastomosis or the subglottic or glottic region. The smaller diameter T-arm is brought out through a stoma in the anterior tracheal wall. The opening in the T-arm can be corked or plugged, and the patient, therefore, breathes through the nose and mouth-which permits speaking and, more importantly, prevents the complications of dessication and crusting as a result of the drying effects of an open tracheostomy. We have used this tube with good effect in 12 patients during the past 7 or 8 years. We have used it as a definitive method of treatment for subglottic or laryngeal injury with stenosis in four patients. In each case the tube remained in place for I year or longer. In two patients with failed reconstructions following segmental resection, the T-tube has been used as a permanent airway. Of more interest to the present discussion are the six patients in whom the T-tube was used as a complement or adjunct to segmental resection and reconstruction. In three patients, either the condition of the airway or the general condition of the patient was such that primary resection was not immediately feasible. The Montgomery T-tube was used to maintain the airway and stent the area of the damaged or unhealthy trachea until conditions became more favorable. In three additional patients, the T-tube was used following resection. In two, an extensive resection was done with thyrotracheal anastomosis-and each of these patients had a damaged larynx as well. The Montgomery T-tube was left in for I year in each instance, stenting the subglottic and larynx, with excellent end results in both cases. In the third patient, a partial dehiscence was recognized about 10 days following resection. Restenosis was anticipated and the Montgomery T-tube was introduced and left in place for 9 months, again with an excellent ultimate result. I know that both Dr. Grillo and I consider the Montgomery T-tube a very important addition in the field of tracheal resection and reconstruction. I would like to compliment Dr. Grillo again on the thoroughness and meticulous detail which he has pursued in the follow-up of his patients over the years.
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874 Grillo
DR. PETER B. MANSFIELD Seattle, Wash.
One of the additional areas in which there remains a need for tracheal resections is in infancy. An increasing number of infants are surviving prolonged intubation for infant respiratory distress syndrome. These infants are intubated nasotracheally, and since the tip of the tube is near the carina, the majority of problems are in the distal third of the trachea. Most of these problems, but not all, can be handled by dilatations or local measures within the trachea. A previously intubated 4-week-old child was admitted in severe respiratory distress after a respiratory arrest. Only a 3.5 Fr. umbilical artery catheter would pass the tracheal obstruction. Studies confirmed a long tight stricture which necessitated resection of a distal third of the trachea through a cervical and mediastinal approach, as Dr. Grillo has taught us. In the infant it is possible to bring the carina all the way up to the top of the sternum. The mediastinum is very mobile, and with the use of interrupted suture technique, the operation went in a satisfactory manner. We examined the child with a bronchoscope after the operation and also 4 months later. The trachea is growing, and the child's weight has doubled. I would submit that there will be increased indications for this type of operation in infants. I would like to ask Dr. Grillo if, in addition to his work in puppies, he has any other information regarding tracheal growth following resection in this young age group. DR. ABRAHAM D. MERAV Bronx. N. Y.
Dr. Grillo, Dr. Cooper, and their associates were among the first to demonstrate that excessive pressure exerted by inflatable cuffs on the trachea is the most common cause of tracheal damage in intubated patients. My purpose is to describe a cuff which is designed to minimize such damage. [Slide] Inflatable cuffs seal the trachea with a cuff-totrachea pressure that is continuous and usually higher (sometimes significantly higher) than airway pressure. This is true especially when cuffs are overinflated. An ideal cuff should be free of the hazard of overinflation, and the pressure it exerts on the trachea should not be greater than distal airway pressure. [Slide] At the Montefiore Hospital in the Bronx we designed a cuff which meets these requirements. It has a thin wall, a large diameter, and large openings near its distal end. It resembles a parachute and functions in a similar fashion to a parachute. The cuff distends and seals the trachea as soon as distal airway pressure rises above ambient pressure. The cuff was tested in ventilated dogs and provided excellent airway seal with a cuff-to-trachea pressure that was continuously identical to airway pressure, just as expected. The performance of the parachute cuff is just as good in clinical trials, which we began recently and are still continuing. There is one potential problem, so far only a theoretical one-that of aspiration. To minimize this hazard, patients have been ventilated with an end-expiratory pressure of 5 to 10 ern to prevent cuff-to-trachea pressure from dropping all the way to zero during exhalation.
Thoracic and Cardiovascular Surgery
Since the parachute cuff is self-inflating and its pressure is self-regulating, there is no need to monitor its pressure and there is no possible way of overinflating it. It is anticipated that the use of this cuff in patients who require prolonged mechanical ventilation will further reduce or entirely eliminate cuff-related tracheal damage. I would like to ask Dr. Grillo if it is his opinion that modern inflatable cuffs have solved the problem of tracheal damage or if efforts to improve cuff design are still worthwhile. DR. WILLIAM E. NEVILLE Newark. N. J.
Certainly one cannot argue with success, and I rise simply to commend Dr. Grillo on his excellent results. The straight silicone tracheal prosthesis has been utilized in 24 patients. In 14 the involved cartilaginous area of the trachea was resected and the membranous portion was left intact. The prosthesis was invaginated upward and downward and anchored by a few sutures to the remaining trachea. In IO patients a primary anastomosis was interposed between the cephalad and caudad margins of the trachea following resection. In this group six patients had an initial stricture and four had a tracheostomy at the time of operation. Recurrent strictures were present in 16 patients and all of these individuals had an existing tracheostomy. One patient had a tracheoesophageal fistula and another had tracheomalacia. The complications are similar to those observed by Dr. Grillo following a primary anastomosis. We also are now using Vicryl sutures instead of Prolene because we believe that the suture line granulomas in three patients were caused by the nonabsorbable sutures. Distal angulation of the prosthesis was seen in one patient. There was one early death from a cerebrovascular accident, and there were two late deaths. One was caused by innominate artery erosion 2 years following operation, and the other was caused by a lung abscess in a patient who had severe bronchiectasis prior to operation. DR. G R ILL 0 (Closing) I appreciate all of the comments. I want to thank Dr. Pearson for his comments and his amplification with the splendid series from Toronto General Hospital (TGH). Over the years, we have had a constant and free interchange of information between MGH and TGH. I wish to thank him and his associates for this dialogue over these years. The Montgomery T-tube is a superb instrument when used appropriately. I elected to use T-tubes in approximately six patients not operated upon for reason of length of tracheal destruction. I believe this to be a safer way to handle such problems than to attempt a massive resection with either staged reconstruction or a prosthesis. Incidentally, all but one of those six patients had had prior reconstructive attempts which had failed. Dr. Mansfield, your experience is important because there are few cases worldwide of infants treated by tracheal resection. Experience therefore has to be accumulated in this way. The youngest patients in this series were 12 years old.
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Younger patients with tube injuries have been handled conservatively. With growth and splinting they have managed to get along. I have seen relatively few stenoses of the type described here in children, so I cannot answer your question precisely. In extensive experiments in puppies we found that the trachea grows to about 85% of the expected amount providing there is not excessive tension. Tension creates more of a problem in puppies than in adult dogs and probably more in children than in adults. Dr. Merav, I certainly am not the one to say the last word about tracheostomy cuffs. Years ago, Drs. Cooper, Pontop-
875
pidan, Geffin, and I described a large-volume, low-pressure cuff made of extensible latex which has produced no injuries to the trachea in thousands of patients. Plastic cuffs, however, are generally inextensible, so that if used beyond the volume range intended, they produce injuries. A fair number of the tracheal injuries presented were produced by "low-pressure", large-volume plastic cuffs. Thus there is still an area for work, perhaps in the area of polymer chemistry. Dr. Neville, when primary reconstruction is not feasible, I prefer the simple and safe insertion of a silicone Montgomery T-tube to the complex open insertion of a silicone prosthesis.
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