Tracheal Anastomosis Research Articles

Airway Management in Tracheal Resection and Anastomosis – Challenges and Novel Solutions!

Airway management in tracheal resection and anastomosis is very challenging. The technique of securing the airway depends on the degree and location of stenosis. Multidisciplinary planning and good communication are the keys to the successful management of these cases. The technique used to maintain the airway and ventilation may vary and needs to be chosen on a case-to-case basis.

Management of COVID-19-related post-intubation tracheal stenosis.

The Severe Acute Respiratory Syndrome Coronavirus 2 (SARS-CoV-2) pandemic has affected Italy since the beginning of 2020. Endotracheal intubation, prolonged mechanical ventilation, and tracheostomy are frequently required in patients with severe COVID-19. Tracheal stenosis is a potentially severe condition that can occur as a complication after intubation. The aim of this study was to evaluate the utility and safety of endoscopic and surgical techniques in the treatment of tracheal stenosis related to COVID-19. Between June 2020 and May 2022, consecutive patients with tracheal stenosis who were admitted to our surgical department were considered eligible for participation in the study. A total of 13 patients were included in the study. They consisted of nine women (69%) and four men (31%) with a median age of 57.2 years. We included seven patients with post-tracheostomy tracheal stenosis. Bronchoscopy was performed to identify the type, location, and severity of the stenosis. All patients underwent bronchoscopic dilation and surveillance bronchoscopy at 7 and 30 days after the procedure. We repeated endoscopic treatment in eight patients. Three patients underwent tracheal resection anastomosis. Final follow-up bronchoscopy demonstrated no residual stenosis. The incidence of and risk factors associated with tracheal stenosis in critically ill patients with COVID-19 are currently unknown. Our experience confirms the efficacy and safety of endoscopic management followed by surgical procedures in cases of relapsed tracheal stenosis.

Analysis of Complications in (Crico-) Tracheal Resection Anastomosis in Adults: A Multicenter Study.

The gold standard treatments for advanced laryngotracheal stenosis (LTS) are represented by partial crico-tracheal (PCTRA) or tracheal resection and anastomosis (TRA). These procedures are potentially burdened by high postoperative complication rates. We investigated the impact of the most common stenosis and patient-related characteristics on the onset of complications in a multicentric cohort. We retrospectively analyzed patients who underwent PCTRA or TRA for LTS of different etiologies in three referral centers. We tested the effectiveness of these procedures, the impact of complications on the outcomes, and identified factors causing postoperative complications. A total of 267 patients were included in the study (130 females; mean age, 51.46 ± 17.64 years). The overall decannulation rate was 96.4%. Altogether, 102 (38.2%) patients presented at least one complication, whereas 12 (4.5%) had two or more. The only independent predictor of post-surgical complications was the presence of systemic comorbidities (p=0.043). Patients experiencing complications needed additional surgery more frequently (70.1% vs. 29.9%, p < 0.001), and had a longer duration of hospitalization (20 ± 10.9 vs. 11.3 ± 4.1 days, p < 0.001). Six of 102 (5.9%) patients with complications had restenosis, although this event did not occur among patients without complications. PCTRA and TRA have an excellent success rate even when performed for high-grade LTS. However, a significant percentage of patients may experience complications associated with a longer duration of hospitalization or the need for additional surgeries. The presence of medical comorbidities was independently related to an increased risk of complications. 4 Laryngoscope, 133:2910-2919, 2023.

CT measurements of tracheal diameter and length in normocephalic cats.

The aim of this study was to measure the tracheal dimensions of normocephalic cats using CT. CT images of 15 client-owned normocephalic cats were retrospectively evaluated to measure the length of the feline trachea. Transverse and vertical inner diameters were measured in five different tracheal regions, and the cross-sectional area of the tracheal lumen was calculated for each point of measurement. Descriptive statistics were applied using a two-tailed t-test. The mean ± SD length of the trachea was 125.13 ± 14.41 mm. Male cats had significantly larger tracheas than female cats. The transverse diameter first increased by 0.94 mm between the most cranial point of measurement and the middle of the trachea. It then decreased by 1.38 mm between the middle of the trachea and the most caudal point of measurement. The vertical diameter decreased by 1.16 mm between the first point of measurement and the penultimate point, and then increased by 0.06 mm between the penultimate point of measurement and the end of the trachea. The two different diameters resulted in an elliptical trachea shape. The feline trachea was circular only at its cranial and caudal ends, and elliptical with a dorsoventral flattening along the rest of its length. Vertical and transverse diameters varied along the entire length. Tracheal shape differences should be considered when performing permanent tracheostomy, tracheal anastomosis or stenting in cats.

Surgical management of tracheal anastomosis failure and risk of arterial bleeding

To determine the optimal algorithm for tracheal anastomotic insufficiency and prevention of arterial bleeding. We present 2 patients with defects of tracheal anastomosis after tracheal resection and divergence of tracheal edges. We primarily analyzed appropriate emergency care and prevention of subsequent severe complications such as arterial bleeding and respiratory insufficiency. Tracheostomy may be preferable for complete late tracheal anastomotic insufficiency to restore breathing. However, surgery should be accompanied by prevention of arterial bleeding. Isolation of damaged area, particularly tracheostomy tube, from the mediastinum by well-vascularized tissues can prevent bleeding from major vessels (for example, innominate artery). Follow-up is unreasonable due to worsening of clinical situation, risk of hemorrhagic complications and fatal outcomes. General satisfactory clinical status of the patient is not of matter. Repeated tracheal anastomosis is justified only for early insufficiency, i.e. within 2-3 days when postoperative inflammation is mild.

Surgical Management of Post-Intubation Tracheal Injuries: A Single-Center Experience from Nepal

Introduction: Despite various improvements in technology and patient care, tracheal intubation and tracheostomy still result in significant tracheal injuries like stenosis and airway fistula. Pressure necrosis by the inflated balloon is the commonest culprit. Post-intubation tracheal stenosis is a major indication for tracheal resection and anastomosis. This study was done to find out the indications and results of surgery for post-intubation tracheal lesions. Methods: It was a descriptive observational study of patients with post- intubation tracheal lesions managed in Manmohan Cardiothoracic Vascular and Transplant Center over a period of 20 years (2001 to 2021). Results: Twenty-five patients were treated for post-intubation tracheal lesions. Four had isolated tracheo-esophageal fistula (TEF); eighteen had an isolated tracheal stenosis and three had both. Most had a tracheal resection and end-end anastomosis (REEA) via a cervical approach, resecting an average of 2.7 cm of tracheal length. The average size of stenotic lumen was 4.32 mm. There were no operative deaths. Two patients expired within a month of surgery: one due to fatal restenosis and the other due to sepsis. There were a few immediate and a few long-term complications. The average follow-up period was 5 years. Conclusion: Among the various post-intubation lesions, tracheal stenosis is the commonest indications for surgery. The management is challenging but safe and feasible, with a multidisciplinary team approach.

Cadaveric Feasibility Study of Knotless Barbed Suture for Tracheal Anastomosis in Dogs

Cadaveric Feasibility Study of Knotless Barbed Suture for Tracheal Anastomosis in Dogs

Outcomes of tracheal resection and anastomosis for post intubation tracheal stenosis: a study of 12 cases

Post intubation tracheal stenosis is a severe clinical condition with an increasing prevalence due to the advances of critical care medicine. This is a retrospective study including 12 cases of post-intubation tracheal stenosis managed by TRA in our head and neck surgery department between the years 2013 and 2019. All patients underwent preoperative clinical evaluation based on neck CT scan and endoscopy under general anaesthesia. Traffic road accidents and trauma were the main causes of prolonged intubation. Ten (10) patients required tracheostomy. According to the Cotton Meyer grading, 4 patients had grade II, 2 had grade III and 4 had grade IV. The mean length of stenosis was 16.2±5.6 millimeters. T-tube was inserted intraoperatively in 5 patients. 4 were successfully decannulated in a mean delay of 9.2 months. Early postoperative complications were subcutaneous emphysema, laryngeal edema, aspiration pneumonia, intra-tracheal migration of the T-tube, and vocal cord paralysis each complication occurred in 1 case. Late postoperative complications were granulation tissue formation observed in 5 cases and restenosis in 3 cases. The initial success rate of the TRA was 91.7%. Management of Post intubation tracheal stenosis requires a skillful multidisciplinary team. TRA guided by a meticulous preoperative evaluation is the gold standard. Keywords: tracheal resection, anastomosis, tracheal resection with end-to-end anastomosis, cervical computed tomography

Critical Care and Postoperative Management of the First Human Long Segment Orthotopic Tracheal Transplantation.

The recipient required reconstruction of a long segment tracheal defect from a previous prolonged intubation. A male donor was chosen for a female recipient to enable analysis of the reepithelialization kinetics using fluorescence in situ hybridization to analyze the source of the new ciliated epithelium. Transplant ICU at the Mount Sinai Hospital, New York, NY. The female recipient was previously intubated for an asthma exacerbation and subsequently developed long segment tracheal stenosis and failed conventional management including dilatation, stenting, and six major surgical procedures rendering her chronically tracheostomy-dependent. The male donor suffered a massive subarachnoid hemorrhage and was subsequently pronounced brain dead. Organ procurement occurred after obtaining appropriate consent from the patient's family. The patient received a deceased donor tracheal allograft that included the thyroid gland, parathyroid glands, and the muscularis of the cervical and thoracic esophagus. Triple therapy immunosuppression (tacrolimus, mycophenolate mofetil, and a corticosteroid taper) was maintained. The patient was initially managed postoperatively with deep sedation on ventilator via armored/reinforced endotracheal tube placed through a small tracheostomy located along the superior tracheal anastomosis. Serial bronchoscopies were performed for graft assessment, pulmonary toilet, and biopsies, which initially showed acute inflammatory changes but no features of acute allograft rejection. A euthyroid state was maintained but hypercalcemia developed. The ICU management of this first long segment orthotopic tracheal transplant required a multidisciplinary approach involving critical care, otolaryngology, transplant surgery, interventional pulmonary, endocrinology, 1:1 nursing throughout the recipient's transplant ICU stay, and respiratory therapy that resulted in the successful establishment of a viable tracheal airway and heralded the end of chronic tracheostomy dependence.

Tracheal Resection Anastomosis: A Retrospective Analysis of 33 Cases

ABSTRACT Introduction Laryngotracheal stenosis (LS) is most commonly caused by iatrogenic injury, namely, tracheal intubation. The goal of treatment is the maintenance of a patent airway, which is mostly achieved by surgical intervention. Our objective was to study the effect of perioperative variables on tracheal resection anastomosis (TRA)/cricotracheal resection anastomosis (CTRA) surgical outcomes by identifying statistically significant factors associated with postoperative complications and failure of surgery, i.e., restenosis. Methods Data from the medical records of 33 patients who underwent TRA/CTRA was analyzed by univariate and multivariate logistic regression. The data included perioperative variables such as the etiology of stenosis, comorbidities, and postoperative or long-term complications. Results The study included nine females and 24 males, and most (29, 87.88%) were intubated prior to surgery. Nineteen patients (57.57%) developed one or more postoperative complications, including, but not limited to, surgical site infection and hematoma. Of all patients, six (18.18%) developed long-term restenosis. Multiple factors were significantly associated with the development of postoperative complications. Univariate analysis revealed the following factors as statistically significant: age (p = 0.05), diabetes (p = 0.00001), hypertension (p = 0.00001), and myocardial infarction (p = 0.03). Multivariate analysis showed that age (p = 0.046) and myocardial infarction (p = 0.00001) were independent factors. The study had an overall survival of 97%. Conclusion TRA/CTRA is a complex surgical procedure, and its outcomes can be affected by many factors. More studies with bigger sample sizes are needed to better understand contributing factors and to confirm the already established associations.

506. MANAGEMENT OF POST INTUBATION TRACHEO-ESOPHAGEAL FISTULA. HOW, WHEN AND WHY TO FACE OFF A POTENTIALLY FATAL INJURY

Abstract Post-orotracheal intubation tracheal injuries are rare but potentially fatal events. The data in the literature show differences in incidence for single-lumen and double-lumen tube intubations. Esophageal involvement may evolve into mediastinitis with poor prognosis. Treatment depends on the location of the lesion, size, extent and the patient's status. Timing and multidisciplinary team evaluation is mandatory for best decision. In a multi-centric observational study between January 2018 and December 2021 we observed 6 consecutive patients with iatrogenic post oro tracheal intubation tracheo-esophageal laceration underwent to multidisciplinary management. 4 patients were treated with end-to-end tracheal resection and anastomosis and closure of the esophageal fistula with cervicotomy access + interposed muscle flap without esophageal exclusion 1 patient was treated with tracheostomy and anterior fistula repair with cervicotomy access + esophageal exclusion 1 patient was treated conservatively for poor performance status. Surgical treatment was within 12 hours from diagnosis. 30-days mortality was observed in one case. Post-orotracheal intubation tracheal injuries are rare but potentially fatal events. Fast and multidisciplinary decision with aggressive treatment are the goal to improve results and reduce mortality.

Tracheal resection and anastomosis in a dog with an osteochondroma

AbstractA 2‐month‐old golden retriever was presented with a history of intermittent wheezing and inspiratory stridor. Previous thoracic radiographs revealed the presence of a discrete opacity partially obscuring the trachea at the level of the thoracic inlet. Through tracheoscopy, a smooth, broad‐based intratracheal mass was visualised just past the thoracic inlet that made up about 80% of the tracheal diameter. Histological examination of biopsies obtained during this procedure was consistent with tracheal osteochondroma. The mass was removed by resection and anastomosis of the trachea through a cervical approach. Histopathology of the excised mass confirmed the prior diagnosis of osteochondroma. Re‐evaluation and repeat thoracic radiographs 6 months postoperatively showed complete resolution of clinical signs and no evidence of recurrent disease. This case demonstrates that tracheal resection and anastomosis can be a viable and curative surgical procedure for some masses, including osteochondromas, within the trachea.

TRACHEAL BRONCHUS OR BRONCHUS SUIS AND ITS IMPORTANCE IN LUNG TRANSPLANT

TYPE: Late Breaking Abstract TOPIC: Imaging INTRODUCTION: Tracheal bronchus (TB) is an aberrant bronchus arising from within 2cm of right lateral wall of supracarinal trachea. The term, bronchus suis, is given when the entire right upper lobe (RUL) is supplied by this bronchus. CASE PRESENTATION: Incidence is estimated at ∼1% (0.1-5%). TB can be classified into supernumerary - usual bronchial supply to affected lung segment is present or displaced - usual bronchial supply to affected lung segment is absent. It is usually an incidental finding, and most patients are asymptomatic. Occasionally patients may have recurrent RUL pneumonia due to focal emphysema or mucus impaction. Improvisation of airway anastomotic technique is required during lung transplantation (LT). DISCUSSION: 5 cases of donor, and 1 case of recipient TB have been reported in literature. Possible options for the airway anastomosis are en-bloc double LT with a tracheal anastomosis, left single LT alone, bilateral LT with left lung and right middle and lower lobe (following donor lung RUL lobectomy), and bilateral LT with a modified right tracheobronchial anastomosis. En-bloc double LT has higher airway anastomotic complication rate compared to bilateral sequential LT. Length of bronchial stump is made as short as possible in the donor lung to maximize the benefit of pulmonary-to-bronchial collateral blood supply. The neo-upper lobe bronchus created by suturing the apical TB and the RUL bronchus of the donor is anastomosed to the RUL bronchus of the recipient in a double-barrel fashion. CONCLUSIONS: Early identification of TB allows for appropriate recipient selection and advanced surgical planning for successful single or bilateral LT. DISCLOSURE: No significant relationships. KEYWORD: tracheal bronchus, bronchus suis, lung transplant

A New Approach in Airway Management for Tracheal Resection and Anastomosis: A Single-Center Prospective Study

The evaluation of the use of laryngeal mask airways (LMA) as an alternative form of airway management for surgical tracheal reconstruction. A prospective case series. At a single German university hospital. Ten patients. The use of LMA for airway management in surgical reconstruction of the trachea. Ten patients with tracheal stenosis of 50% to 90% were enrolled prospectively during the study period. The airway management consisted of the insertion of an LMA. During resection and reconstruction, high-frequency jet ventilation was used. Several arterial blood gas analyses (ABG) were performed before, during, and after the tracheal resection and reconstruction. All values were presented as median and interquartile ranges or as absolute and relative values, and no emergency change to cross-field intubation was necessary. The lowest PaO2 was 93 mmHg in 1 patient after 20 minutes of jet ventilation, whereas PaO2 increased after the induction phase and remained stable in 9 patients. There were no intraoperative complications related to anesthetic management apart from transient hypercarbia during and after jet ventilation. Preoperative and postoperative ABG were comparable. One patient required immediate postoperative ventilatory support. Two patients developed postoperative pneumonia, leading to their admission to the intensive care unit. One patient was operated with a palliative approach due to massive dyspnea and died in the next postoperative course. The use of LMA is an alternative option in airway management for tracheal reconstruction, even in patients with significant tracheal stenosis. Potential advantages compared to tracheal intubation are unimpaired access to the operative field and the lack of stress on the fresh anastomosis.

Post-intubation Tracheoesophageal Fistula In Severe Sars-cov-2 Covid-19 Patient: An Unexpected Finding During Swallowing Test

Severe acute respiratory syndrome coronavirus 2 (SARS-Cov2) has cause the COVID-19 pandemic that had led to an increase in intensive care unit admission for massive interstitial pneumonia. Many patients underwent mechanical ventilation and endotracheal intubation for a prolonged period of time followed by a subsequent tracheostomy. The most common complications related to these maneuvers are stenosis, malacia, laryngotracheal granulomas, webs. The least common complications are tracheal necrosis due to tracheo-arterial or trachea-esophageal fistulas, caused by compression between the nasogastric tube and the orotracheal tube cuff. A case of 58-year-old female COVID-19 patient with severe pneumonia who underwent prolonged mechanical ventilation and intubation and for two months with unexplained episodes of food inhalation. During the swallowing test, it was observed inhalation, without natural passage of food from the glottic plane. Therefore, ENT specialist in swallowing, suspecting the feared tracheo-esophageal fistula, requested a double contrast esophageal x-ray that confirmed the diagnostic hypothesis. Thoracic surgery team performed surgical correction by resection and tracheal anastomosis with esophagoraffia. TEF is a very rare, but potentially fatal, complication of invasive VM. Predisposing factors are prolonged periods of invasive VM, elevated cuff pressures, oversized endotracheal tubes, patient comorbidities, local and general infections, use of a nasogastric tube. The endoscopic swallow test is a relatively simple test, performed at the patient's bed, that can identify oropharyngeal swallowing disorders and esophageal changes, such as tracheoesophageal fistula.

The effect of suture techniques on the outcome of tracheal reconstruction: An observational study and review of literature

BackgroundTracheal resection and anastomosis surgery is a safe operation and is used to treat various benign and malignant diseases of the trachea. However, tracheal stenosis is among the main anastomotic complications following this procedure. Surgeons use both the continuous and the interrupted suture techniques for tracheal anastomosis, but contradicting results in each technique's complications have been reported in various studies. In this study, we aimed to compare the outcome of these two different suture techniques and a relevant literature review. MethodsSurgical records during a period of 15 years (2005–2019) were screened for tracheal reconstruction surgery in affiliated hospitals of Shiraz University of Medical Sciences, Shiraz, Iran. A total of 82 patients were evaluated based on surgical and suture features, along with their follow-up bronchoscopy for anastomotic complications. ResultsPost-operational subclinical restenosis occurred in 8 (15.3%) out of 52 and 10 (33.3%) of 30 patients who underwent continuous and interrupted suturing techniques, respectively. Also, 6 (20%) patients in the interrupted group developed symptomatic restenosis, while in the continuous group, only one patient was clinically symptomatic. The patients with continuous suture technique had a shorter surgery time than patients whose interrupted technique was used (P < 0.001). ConclusionsBased on our results, we conclude that restenosis is significantly reduced when the continuous technique is applied for tracheal anastomosis; However, the results are contradicting in relevant literature and due to the retrospective nature of our study, further human studies and clinical trials are warranted.

Post-intubation tracheoesophageal fistula in severe SARS-CoV-2 - COVID-19 patient: Unexpected finding during swallowing test

Introduction: COVID-19 pandemic, caused by severe acute respiratory syndrome coronavirus 2, led to an increase in intensive care admission for massive interstitial pneumonia. Many patients underwent long periods of endotracheal intubation for mechanical ventilation and subsequent tracheostomy. The most common complications related to these maneuvers are known: laryngotracheal granulomas, webs, stenosis and malacia. Less common complications are tracheal necrosis with trachea-esophageal or tracheo-arterial fistulas, caused by compression between the orotracheal tube cuff and the nasogastric tube. Case report: We present the case of a patient with severe COVID-19 associated pneumonia who underwent orotracheal intubation and prolonged mechanical ventilation for two months with unexplained episodes of food inhalation. During the swallowing test, it was observed inhalation, without natural passage of food from the glottic plane. Therefore, ENT specialist in swallowing, suspecting the feared tracheo-esophageal fistula, requested a double contrast esophageal xray that confirmed the diagnostic hypothesis. Thoracic surgery team performed surgical correction by resection and tracheal anastomosis with esophagoraffia. Discussion: TEF is a very rare, but potentially fatal, complication of invasive VM. Predisposing factors are prolonged periods of invasive VM, elevated cuff pressures, oversized endotracheal tubes, patient comorbidities, local and general infections, use of a nasogastric tube. The endoscopic swallow test is a relatively simple test, performed at the patient’s bed, that can identify oropharyngeal swallowing disorders and esophageal changes, such as tracheoesophageal fistula.

Analysis of various defects and reconstructive methods after invasive thyroid carcinoma resection

ObjectiveThe thyroid gland adjoins the trachea, pharynx, esophagus, carotid artery and cervical skin. Most thyroid carcinomas have been treated at lower stages; however, in some cases the carcinomas have invaded the surrounding organs. After resecting invasive thyroid carcinomas, the defects vary depending on the invasion area and organs affected; subsequent reconstructive methods vary depending on the size of defect and its components. This study analysed the pattern of defects and the reconstructive methods used following invasive thyroid carcinoma resection. MethodsFrom April 2011 to March 2021, 665 patients in Saitama Cancer Center (Saitama, Japan) were diagnosed with thyroid carcinoma and subsequently underwent thyroidectomies. In the 25 patients (3.8%), the thyroid carcinoma invaded surrounding organs and any reconstructive surgery—including end-to-end tracheal anastomosis and simple pharynx closure—was performed after thyroid carcinoma resection. The patients’ records were retrospectively reviewed, and the defects and subsequent reconstructive methods were analysed. ResultsWhen our new classification system was applied to the defects, the number of cases for each type was totaled: Tr0: 1; Tr1a: 3; Tr2b: 5; Tr3a: 1; La-Tr3b+PE2: 7; La-Tr3b+PE2+S2: 1; PE1: 1; PE1+S1: 2; S1: 2; S2: 2. For Tr0, a tracheal fenestration was performed after the tumor resection and the fenestration was closed with a hinge flap. For Tr1a defect, a tracheal fenestration was performed with cervical skin after the tumor resection and the tracheal fenestration was closed with a deltopectoral flap or pectralis major musculocutaneous flap. In one recent patient, the tracheal fenestration was reconstructed using free forearm flap and cervical skin, and the fenestration was closed with a hinge flap. For Tr2b defect, free forearm flap and costal cartilage graft reconstruction was performed after the tumor resection and the fenestration was closed with a hinge flap. For Tr3a defect, end-to-end anastomosis was performed in one patient. For La-Tr3b+PE2 defect, total pharyngolaryngectomy with free jejunal flap reconstruction was performed. For PE1 defect, a simple closure was performed in one patient and a PMMC muscle flap was used for covering the suture line in two patients. For S1 and S2 defect, PMMC flap or DP flap was used. ConclusionOur analysis of defects and reconstructive methods defines the complex defect patterns occurring after invasive thyroid carcinoma resection, describes the patterns of subsequent reconstructive methods.

Sequential Redo Bilateral Lung Transplantation in a Patient with a Prior Heart-Lung Transplantation with Tracheal Anastomosis

<h3>Introduction</h3> Redo lung transplantation (LT) for chronic lung allograft dysfunction (CLAD) is technically complex. We present a redo bilateral LT after previous heart-lung transplantation (HLT) with salvage of tracheal anastomosis and donor-to-donor main bronchi anastomoses. <h3>Case Report</h3> Patient is a 22-year-old male with previous HLT 17 years prior for pulmonary arterial hypertension now with preserved cardiac function, CLAD (FEV1 36%) with chronic hypercapnic respiratory failure, and pulmonary fungal infection with multidrug resistant <i>Lomentospora prolificans</i>. Prior to listing sputum culture was negative for fungal growth. His LAS was 45.8, and he spent 36 days on the wait list prior to a suitable donor being identified. Surgical approach involved redo clamshell thoracotomy. To control for possible fungal dissemination both lungs were explanted simultaneously under cardiopulmonary bypass, and extensive irrigation of chest cavities and trachea was completed with amphotericin B and caspofungin. The prior tracheal anastomosis was left intact. Pump suction and cell salvage was avoided. Standard sequential implantation with donor-to-donor main bronchi anastomoses was completed. Lung explant pathology demonstrated active subtotal and total bronchiolitis obliterans (C1) associated and necrotizing and non-necrotizing granulomas. Primary graft dysfunction was grade 1 at time 0, 24, 48, and 72 hrs. Postoperative antifungal regimen was Olorofim, caspofungin, and inhaled amphotericin B. No short-term airway complications were encountered. First transbronchial biopsy (TBBx) demonstrated moderate acute cellular rejection (ACR; A3B2), and <i>Lomentospora prolificans</i> growth. Due to persistent fungal growth, but no evidence of fungal pneumonia on chest imaging, systemic antifungal regimen was adjusted to fosmanogepix, miltefosine, posaconazole, and caspofungin. After 5 days of new antifungal regimen, 500 mg methylprednisone x 3 days was administered for ACR. Patient was discharged home on POD32. Second TBBx demonstrated no ACR but fungal elements persisted. <h3>Summary</h3> Redo bilateral LT after HLT with salvage of tracheal anastomosis and donor-to-donor main bronchial anastomosis is feasible without airway complications. Antifungal regimen will continue with re-evaluation at 6 months postoperatively.

Post-COVID-19 airway stenosis treated by tracheal resection and anastomosis: a bicentric experience.

SUMMARYObjectiveThe COVID-19 pandemic was an extraordinary challenge for the global healthcare system not only for the number of patients affected by pulmonary disease, but also for the incidence of long-term sequalae. In this regard, laryngo-tracheal stenosis (LTS) represents one of the most common complications of invasive ventilation.MethodsA case series of patients who underwent tracheal resection and anastomosis (TRA) for post-COVID-19 LTS was collected from June 2020 to September 2021.ResultsAmong 14 patients included, 50% had diabetes and 64.3% were obese. During intensive care unit stay, mean duration of orotracheal intubation (OTI) was 15.2 days and 10 patients (71.4%) underwent tracheostomy, which was maintained in 7 for an average of 31 days. According to the European Laryngological Society classification, 13 patients (92.9%) had a grade IIIa LTS and one a grade IIIa+. All patients underwent Type A TRA, according to the authors’ classification. No major perioperative complications were reported and at the last follow-up all patients were asymptomatic.ConclusionsWith the appropriate indications, TRA represents an effective treatment in post-COVID-19 LTS patients. Short OTI times and careful tracheostomy are required in order to reduce the incidence of airway injury.