Management of intrathoracic tracheal stenosis: a challenge

Abstract

BackgroundTracheal stenosis is a complicated surgical problem, which because of endoscopic techniques can be managed by less invasive procedures. In our case series of three patients with intrathoracic tracheal stenosis following prolonged use of tracheostomy tube, we describe the initial assessment, investigations, management, and post-operative results of the same. In our series, all three patients were tracheostomised (with a metallic tube) for more than 3 months. This resulted in chronic abrasion of intraluminal tracheal mucosa at thoracic level. We managed them with conservative trans-oral and trans-tracheal laser-assisted release instead of open surgeries like trachea-tracheal resection and anastomosis or Crico-tracheal resection and anastomosis.ResultsIn our case series, we chose transoral bronchoscopic fibre laser-assisted release followed by dilatation for one patient and trans-tracheal release for the other two. In the trans-oral case, we faced difficulty in controlling the long length of instruments, thereby effecting the control over the laser tip and precision of cut. During the revision surgery for the same patient, we faced difficulty in securing the airway below the stenosis as it was a low stenosis. In patients 2 and 3, we approached the stenosis site via tracheostomy site, thereby significantly reducing the working length of instruments. This gave us better control over the instruments and we attained better precision in radial incisions. Moreover, if there had been an intraoperative bleeding or aspiration, we could have easily secured the airway by FROVA as distance between stoma and stenosis site was not very long.ConclusionCO2 Lase-assisted stenosis release has a very promising result in up to grade III thoracic tracheal stenosis. A good preplanning with anaesthetists and cardiothoracic surgeons for tailor made approach is a must. Intermittent apnoea technique of anaesthesia really helps in such cases of intrathoracic tracheal stenosis. We advocate to always use soft material tracheostomy tube to prevent mucosal abrasion, to avoid a low tracheostomy without appropriate and to proper fix the tracheostomy tube and try for early decannulation.