Tracheal Laceration Research Articles

A New Endoscopic Technique for Intraluminal Repair of Posterior Tracheal Laceration

This report describes an endoscopic repair of a tracheal tear with a newly developed optical needle holder. No surgical access was necessary. A 71-year-old woman with a 5-cm gaping iatrogenic tracheal laceration and a distinctive mediastinal and subcutaneous emphysema was successfully repaired with an endotracheal running suture through a 14-mm rigid tracheoscope. Operation time was 105 minutes, and borderline jet ventilation was used to maintain oxygen saturation. A bronchoscopy 9 days later revealed the tracheal tear had completely closed and the running suture was in place. No postoperative complications were noted.

Tracheal Rupture after Intubation of Endotracheal Tube for Laser Operation

A case of extensive pneumomediastinum and subcutaneous emphysema is presented, after endotracheal intubation with a metallic endotracheal tube during laser epiglottectomy. A 69 year old woman had a laser tube intubation-related tracheal injury. The patient was managed with intubation and chest tube insertion as well as antibiotic treatment. The patient made a full and uncomplicated recovery and was discharged 10 days after the original injury. Aggressive surgical repair for such injuries is not always mandatory. In the absence of infectious complications, a conservative approach is an option for lesions 3 cm above the carina where it is possible to inflate a cuff. Urgent chest CT scanning subsequently can confirm extensive mediastinal and subcutaneous emphysema and probable tracheal laceration. The use of a laser tube during laser laryngeal microsurgery requires meticulous care. Korean J Otorhinolaryngol-Head Neck Surg 2010;53:47-9 Key WordsZZTracheal rupture·Pneumomediastinum·Subcutaneous emphysema·Endotracheal tube·Laser surgery.

Tracheal rupture after emergency endotracheal intubation

A 60-year-old woman presented to the emergency department (ED) of a suburban hospital with complaints of cough, fever, and dyspnea. She had a history of chronic obstructive pulmonary disease (COPD) and chronic steroid therapy. At presentation, she was in severe respiratory distress. Orotracheal intubation was decided due to persistence of severe hypoxia and hypercapnia with deterioration of consciousness despite a first attempt at noninvasive ventilation. The intubation was performed in rapid sequence using a 7.5-mm diameter single lumen tube without stylet. The patient had a regular and anatomically intact airway. The maneuver itself was reported to be an easy procedure and was considered successful after the first attempt. After about an hour of invasive ventilation, a subcutaneous emphysema appeared on the neck and anterior chest wall, respiratory failure worsened, and a slight hemoptysis occurred. The chest radiograph showed subcutaneous emphysema and protrusion of the cuff outside the tracheal lumen (Fig. 1). A computed tomography (CT) scan visualized the injury of the posterior tracheal wall due to the rupture of the pars membranacea (Fig. 2). The patient was then referred to our hospital to undergo a bronchoscopy, which revealed a longitudinal hole with sharp margins at the posterior part of the membranous portion, extending up to 2 cm from the carina with a total length of 5 cm. The lesion was surgically repaired via right thoracotomy. Fig. 1 a Chest radiograph in the anteroposterior view of the patient with tracheal rupture, showing subcutaneous and mediastinal emphysema. b Detailed view shows the protrusion of the cuff of the tube outside the tracheal lumen (white arrows) Fig. 2 a–c Corresponding CT axial scans corroborating the diagnosis of subcutaneous and mediastinal emphysema. d The lumen of the tracheal tube appears enlarged and deformed after the herniation of the cuff Mechanisms that may determine tracheal laceration are mechanical and anatomical [1]. An over-distended balloon cuff coupled with fragility of the tracheal wall due to chronic lung diseases and steroid therapy may be crucial [2]. The appearance of specific symptoms after intubation, like subcutaneous emphysema, hemoptysis, and persistence of hypoxia despite adequate ventilation, are consistent with a possible tracheal rupture [1–4]. Radiology may confirm the clinical suspicion.

Tracheal lacerations after endotracheal intubation: a proposed morphological classification to guide non-surgical treatment☆☆☆

Postintubation tracheobronchial lacerations (PITLs) are traditionally managed surgically. We sought to evaluate the rationale for non-surgical management of PITL. From January 2003 to November 2008, 30 patients with PITL were observed in our institution. PITL were graded as follows: Level I - mucosal or submucosal tracheal involvement without mediastinal emphysema and without oesophageal injury; Level II - tracheal lesion up to the muscular wall with subcutaneous or mediastinal emphysema without oesophageal injury or mediastinitis; Level IIIA - complete laceration of the tracheal wall with oesophageal or mediastinal soft-tissue hernia without oesophageal injury or mediastinitis; Level IIIB - any laceration of the tracheal wall with oesophageal injury or mediastinitis. All patients with Level I, II and IIIA PITL were treated conservatively with endoscopic instillation of fibrin glue (Tissucol, Baxter Healthcare, Deerfield, MA, USA). All patients with Level I (n=3), II (n=24) and IIIA (n=2) PITL were successfully treated conservatively. The patient with a Level IIIB injury underwent posterolateral thoracotomy repair of the trachea. No mortality was reported. Mean hospital stay was 12.9 days. Flexible bronchoscopy at 7, 28, 90 and 180 days showed no abnormalities. Complete healing was attained in all patients by day 28. Level I or II PITL should be managed non-surgically. When adequate respiratory status is present, Level IIIA PITL can be managed conservatively in selected institutions only, because these injuries are high-risk injuries. Any PITL associated with injury involving the oesophagus or with mediastinitis (Level IIIB) must be treated as soon as possible by surgery.

Laceração traqueal pós-intubação: análise de três casos e revisão de literatura

Post-intubation tracheal injury is a rare and potentially fatal complication. Among the most common causes, cuff overinflation and repetitive attempts of orotracheal intubation in emergency situations are paramount. Diagnosis is based on clinical and radiological suspicion, confirmed by fiberoptic bronchoscopy. Both conservative and surgical management apply, and the decision-making process depends on the patient profile (comorbidities, respiratory stability), characteristics of the lesion (size and location) and the time elapsed between the occurrence of the injury and the diagnosis. We report the cases of three patients presenting tracheal laceration due to traumatic orotracheal intubation, two submitted to surgical treatment and one submitted to conservative treatment.

Blunt posterior tracheal laceration and esophageal injury in a child

Blunt force trauma to the neck can result in the unusual injury pattern of laceration of the posterior tracheal wall in combination with esophageal injury. We present the report of a 10-year-old child who had blunt cervical trauma because of a bicycle accident and subsequently presented with profound subcutaneous emphysema. This case was addressed with operative management with a good result. The essential management principles for this rare constellation of injuries include a high index of suspicion, early control of the airway, endoscopic and radiographic diagnosis, and use of a buttressing strap muscle flap in the event of operative management to prevent delayed complications, including leak and tracheoesophageal fistula.

A novel surgical technique of repair of posterior wall laceration of thoracic trachea during transhiatal esophagectomy

Tracheal injury is a rare, dreaded and potentially fatal complication of transhiatal esophagectomy (THE). The close proximity of major airway to esophagus makes it vulnerable to iatrogenic laceration during mediastinal manipulations. Over a period of five years, three patients with injury to membranous trachea during THE, were managed through the cervical incision. There was laceration of membranous trachea ranging from 3.5 to 5 cm in length with minimal loss of tracheal tissue. One of the lacerations was extending up to the right bronchus. All the patients were successfully managed through the cervical incision. The operative repair of trachea lasted for 45-60 min. One patient developed permanent left recurrent laryngeal nerve injury and another had postoperative bronchopneumonia. There was no mortality. Trans-cervical approach is an effective way of repairing thoracic membranous tracheal laceration during THE without any significant increase in the morbidity.

Esophagectomy without thoracotomy: 25 years of experience over 750 patients

ObjectiveThis study aimed to review and evaluate our experience in 750 patients, who underwent transhiatal esophagectomy (THE) and analyze our data. Special attention was paid to some strategies, which we developed in the course of time, regarding the postoperative management of these patients and formulation of improved guidelines.Patients and methodsThis is a retrospective analysis of all THE operations performed between January 1981 until May 2007 in 750 patients: 60 patients (8%) had benign lesions, while 690 (92%) had malignant ones (5.2% of malignancies were located in the upper esophagus, 7.4% in the middle esophagus, 19% in the lower esophagus, and 68.4% at the cardioesophageal junction). THE and esophageal reconstruction were performed at the same operation in all patients. The stomach was our esophageal substitute of first choice with the colon and jejunum being acceptable alternatives in patients with prior gastric surgery and those necessitating synchronous gastrectomy for cancer invasion. A gastric tube was used as an esophageal substitute in 624 patients (83.2%), the whole stomach in 70 (9.4%), the colon in 43 (5.73%), and a jejunal loop in 13 (1.73%).ResultsThe overall in-hospital mortality rate was 2.93% (22 patients). There was no intraoperative death. Major complications included atelectasis or pneumonia (4.8%), pleural effusion (22.7%), myocardial infarction (0.5%), recurrent laryngeal nerve paralysis (1.33%), and three tracheal lacerations (0.4%). The anastomotic leak rate decreased gradually over time from 29.4% to 11.1% in the last 6 years. The average intraoperative blood loss was 315 ml and 82% of the patients did not receive any blood transfusion. Late functional results were good or excellent in 93%. The average length of hospital stay was 11 days and intensive care unit stay was 2.3 days. The actuarial 5-year survival rate after THE for carcinoma was 21%.ConclusionTHE is a safe and effective method of esophageal resection with low morbidity and mortality rates and good functional results when performed by experienced surgeons. We believe that our strategies concerning the way of dissecting the cervical esophagus, avoidance of performing pyloromyotomy, the delayed removal of the cervical drain and the delayed advance to oral feeding have reduced, noticeably, morbidity and mortality in our series.

Incidence and treatment modalities of tracheobronchial injuries in Germany

This study presents the first systematic data collection on incidence and therapeutic management of both iatrogenic and non-iatrogenic tracheal lacerations in Germany. In this survey (n=231 questionnaires) based on the geographical coverage of the country, the representation of all levels of service, and the inclusion of specialized thoracic departments as well as non-specialized surgical departments, a representative conspectus on the management of tracheal injuries in Germany was developed. A total number of 1033 tracheal injuries were reported; n=429 of non-iatrogenic origin (blunt trauma: n=276, penetrating wounds: n=94, bullet wounds: n=16, other etiology: n=43) and n=604 of iatrogenic origin (endotracheal intubations/mechanical ventilation: n=372, dilative tracheotomy: n=181, endoscopic interventions: n=51). In institutions of high level of service there was a trend towards higher rates of surgical repair as opposed to conservative management. On the basis of these data the estimated risk of tracheal lacerations, due to single lumen intubation was 1:75,000 (0.000013%); the risk of clinically significant tracheal lacerations due to dilative tracheostomy 1:575 (0.002%) and lacerations requiring surgical treatment 1:975 (0.001%). Data of this survey state that specialized thoracic surgeons to a high proportion are involved in the management of both iatrogenic and non-iatrogenic tracheal injuries.

Thyroid Emphysema Following Penetrating Neck Trauma

Although traumatic thyroid gland rupture or hemorrhage is usually seen in goitrous glands, injuries of the normal thyroid gland after neck trauma have rarely been described in the literature. We describe a 44-year-old man who presented with thyroid emphysema and subcutaneous emphysema (SCE) that occurred after penetrating neck trauma. CT images showed complete resolution of thyroid emphysema and subcutaneous emphysema at follow-up examination. Neck injuries can be life threatening. After penetrating neck traumas, physicians should consider subtle esophageal or tracheal laceration. Thyroid emphysema can occur as the result of penetrating neck trauma. The mechanism of emphysema of the thyroid parenchyma can be explained by the thyroid gland's presence in a single visceral compartment that encompasses the larynx, trachea and thyroid gland. We describe an unusual case of thyroid emphysema of a normal thyroid gland following a penetrating neck injury.

Tracheal laceration detected by high end-tidal CO2 during endoscopic thyroidectomy.

Endoscopic thyroidectomy is frequently used for cosmetic reasons, such as reducing cervical scarring. Subcutaneous gas insufflation with CO2 is needed to maintain the surgical space, and optimal surgical techniques and careful attention are required when conducting this procedure due to the limited space available for the endoscopic instruments. We report here a case of a tracheal laceration with a tear in the cuff of a reinforced tube, which was detected by an abrupt increase in end-tidal CO2 to 90 mmHg. Reintubation was achieved using a tube exchanger and the patient was effectively ventilated without complications.

Necessity for additional incisions with the cervical collar incision to remove retrosternal goiters

Retrosternal goiters (RSGs) can be removed transcervically, but additional incisions are sometimes necessary. We examined the factors determining the need for additional incisions to remove an RSG goiter, based on our experience and on an algorithm. Among 499 patients who underwent surgery for a goiter, 52 (10.4%) had an RSG removed via a collar incision. Additional incisions were necessary in 11 patients (21% of those with an RSG and 2.2% overall): a partial sternotomy in 4, total sternotomy in 5, and right thoracotomy in 2. Recurrent nerve paralysis developed in two patients and one patient had a tracheal laceration. There was no mortality. A diagnosis of adenomatous goiter was confirmed in all patients. Additional incisions can be made if thyroidectomy cannot be done transcervically and if the goiter extends to the level of the aortic arch. If the thyroid gland extends below the aortic arch and the lateral diameter of the goiter is greater than 10 cm, a partial sternotomy may be required. Total sternotomy is needed when an RSG extends caudally to the azygos vein, if it is located in the retrotracheal or retroesophageal space, or if it is recurrent or ectopic. Coexisting lung disorders and goiters extending to the left atrium also require thoracotomy.

Major Airway Injury During Esophagectomy: Experience at a Tertiary Care Center

BackgroundTracheal laceration is a rare but life-threatening complication of esophagectomy. It is seen both with transhiatal and transthoracic esophagectomy. MethodsThree hundred eighty-two esophagectomies were performed from 1998 to 2008. The medical records of five patients with laceration of trachea during esophagectomy managed at a tertiary care center were reviewed retrospectively. ResultsThere were three males and two females with age range 18–62 years. The overall incidence of tracheal laceration was 1.31%. Four lacerations (1.30%) occurred during transhiatal and one (1.35%) during transthoracic resection of esophagus. Tracheal laceration was detected intraoperatively in all. Laceration was long (>3 cm) in three patients and short (<2 cm) in two. Patients with long laceration required direct suturing, while those with short laceration could be managed with gastric reinforcement. No patient required additional thoracotomy to access the lesion. Two patients had pneumonia, one had recurrent nerve palsy, while another developed anastomotic disruption. No patient died. ConclusionLaceration of trachea is a potentially morbid complication of esophagectomy. Management should be individualized based on the extent and type of laceration. The surgical strategy depends upon the index procedure. The present series describes successful management of patients with tracheal injury associated with esophagectomy.

EComment: Autologous or bovine pericardial patch for the repair of membranous tracheal wall lacerations?

eComment: Autologous or bovine pericardial patch for the repair of membranous tracheal wall lacerations?

EResponse: Should autologous irradiated pericardium be used for tracheal lacerations?

eResponse: Should autologous irradiated pericardium be used for tracheal lacerations?

P.147 Percutaneous tracheostomy with the Ciaglia Blue Rhino Dilator

To sum up our experience in percutaneous dilatational tracheostomy (PDT) in ICU patient with severe brain injury.Between November 2011 and April 2014, PDTs were performed on 32 severe brain injury patients in ICU by a team of physicians and intensivists. The success rate, efficacy, safety, and complications including stomal infection and bleeding, paratracheal insertion, pneumothorax, pneumomediastinum, tracheal laceration, as well as clinically significant tracheal stenosis were carefully monitored and recorded respectively.The operations took 4-15 minutes (mean 9.1 minutes±4.2 minutes). Totally 4 cases suffered from complications in the operations: 3 cases of stomal bleeding, and 1 case of intratracheal bloody secretion, but none required intervention. Paratracheal insertion, pneumothorax, pneumomediastinum, tracheal laceration, or clinically significant tracheal stenosis were not found in PDT patients. There was no procedure-related death occurring during or after PDT.Our study demonstrats that PDT is a safe, highly effective, and minimally invasive procedure. The appropriate sedation and airway management perioperatively help to reduce complication rates. PDT should be performed or supervised by a team of physicians with extensive experience in this procedure, and also an intensivist with experience in difficult airway management.

Iatrogenic Tracheal Laceration Causing Asphyxia

Endotracheal intubation is a simple, rapid, and safe technique that is being used as a standard procedure for airway management. However, airway injury during endotracheal intubation could be a significant source of morbidity or even mortality for patients and a source of liability for physicians as well. We report an unusual case of fatal tracheal occlusion by intraluminal blood clot complicating endotracheal intubation. The patient, a 62-year-old woman, with renovascular hypertension and incipient renal failure was scheduled for renal autotransplantation. The surgery was uneventful but the postoperative course was complicated with a lethal airway obstruction. At autopsy a linear longitudinal tracheal laceration was identified with an intraluminal blood clot obstructing the tracheal lumen. Tracheal laceration as a cause of death is a rare and potentially fatal complication of endotracheal intubation with intratracheal bleeding, clot formation, tracheal occlusion, and subsequent asphyxia.

Delayed presentation of an isolated tracheal injury following direct blunt anterior neck trauma

Blunt injuries to the cervical trachea are rare but if present, are usually associated with either a direct impact the neck or acceleration—deceleration injuries. Patients with tracheal lacerations or ruptures tend to present acutely with signs of airway embarrassment. Such injuries are associated with concomitant injuries to the cervical structures. This particular type of injury thus presents a diagnostic and therapeutic challenge to emergency physicians, anaesthetists and surgeons alike. We present a case which is extremely rare in its clinical presentation. In addition, we propose a possible alternative way to manage a delayed anterior cervical trachea laceration.

Application of anterior decompression and reconstruction using titanium mesh with locking plates in the management of cervical spondylotic myelopathy

Objective To observe the clinical effect of anterior decompression and reconstruction using titanium mesh with locking plates in the treatment of cervical spondylotic myelopathy. Methods One hundred and twenty patients with cervical spondylotic myelopathy were treated by anterior decompression and reconstruction using titanium mesh with locking plates. There were 66 men and 54 women ranges in age from 37 to 72 Years (mean age, 58.3 years). The mean Japanese orthopedic surgery association (JOA) scale was 9.6 points before operation. Patients were followed up clinically and radiographically. Results Having stood surgery well, the operation time ranged between 60~100 min and bleeding during operation ranged between 20~200 ml. There were no case of postoperative infection, recurrent laryngeal nerve palsy, or esophageal or tracheal laceration or rupture. The average follow-up period was 14.3 months (range, 12 to 24 months) in 96 who were followed up. At the last follow-up visit the mean JOA scale had improved to 14.4 points, reflecting an improvement of 4.8 points. The results were considered to be excellent in 87 patients, good in 25, fair in 6, and poor in 2. No hardware-related complications or adjacent segment degenerative changes were encountered during the follow-up periods. Stable bone union was observed in all cases and the average time required for fusion was 5.7 months. Conclusion Titanium mesh filled with autologous bone graft can avoid the complications associated with harvesting bone from the iliac crest donor site. When combined with cervical anterior locking plate, it can obtain satisfatory clinical results for the treatment of cervical spondylotic myelopathy.

Tracheal laceration following double-lumen intubation during Ivor Lewis esophagogastrectomy

A case of a 48-year-old man with an iatrogenic membranous tracheal wall rupture after double-lumen intubation during Ivor Lewis esophagogastrectomy is presented. Tracheal injury was successfully managed surgically with the use of a bovine pericardial patch and reinforcement with the gastric conduit which was moved toward the posterior wall of the membranous trachea sealing the wall laceration.