Tracheal Surgery Research Articles

Review of the monograph "Reconstructive Tracheal Surgery" by V.D. Parshin and V.A. Porkhanov

The book "Reconstructive Tracheal Surgery" was published in December 2020. It is devoted to the actual problem - tracheal surgery and is written by the leading thoracic surgeons of our country, Professors V.D. Parshin, Corresponding Member of RAS and Acad. V.A. Porkhanov. This field of medicine is complicated and remains the privilege of a limited number of medical institutions. Widespread introduction of respiratory resuscitation, artificial lung ventilation, tracheostomy into clinical practice has led to the emergence of patients with tracheal injury and formation of cicatricial stenosis in them. The number of such patients in our country has no tendency to decrease, despite the progress of resuscitation and anesthesiology.

Tracheal surgery for airway anomalies associated with increased mortality in pediatric patients undergoing heart surgery: Society of Thoracic Surgeons Database analysis

ObjectivesAirway anomalies are common in children with cardiac disease but with an unquantified impact on outcomes. We sought to define the association between airway anomalies and tracheal surgery with cardiac surgery outcomes using the Society of Thoracic Surgery Congenital Heart Surgery Database. MethodsIndex cardiac operations in children aged less than 18 years (January 2010 to September 2018) were identified from the Society of Thoracic Surgery Congenital Heart Surgery Database. Patients were divided on the basis of reported diagnosis of an airway anomaly and subdivided on the basis of tracheal lesion and tracheal surgery. Multivariable analysis evaluated associations between airway disease and outcomes controlling for covariates from the Society of Thoracic Surgery Congenital Heart Surgery Database Mortality Risk Model. ResultsOf 198,674 index cardiovascular operations, 6861 (3.4%) were performed in patients with airway anomalies, including 428 patients (0.2%) who also underwent tracheal operations during the same hospitalization. Patients with airway anomalies underwent more complex cardiac operations (45% vs 36% Society of Thoracic Surgeons/European Association for Cardiothoracic Surgery Congenital Heart Surgery Mortality category ≥3 procedures) and had a higher prevalence of preoperative risk factors (73% vs 39%; both P < .001). In multivariable analysis, patients with airway anomalies had increased odds of major morbidity and tracheostomy (P < .001). Operative mortality was also increased in patients with airway anomalies, except those with malacia. Tracheal surgery within the same hospitalization increased the odds of operative mortality (adjusted odds ratio, 3.9; P < .0001), major morbidity (adjusted odds ratio, 3.7; P < .0001), and tracheostomy (adjusted odds ratio, 16.7; P < .0001). ConclusionsPatients undergoing cardiac surgery and tracheal surgery are at significantly higher risk of morbidity and mortality than patients receiving cardiac surgery alone. Most of those with unoperated airway anomalies have higher morbidity and mortality, which makes it an important preoperative consideration.

Postintubation Multisegmental Tracheal Stenosis: A 24-Year Experience

Management of multisegmental tracheal stenosis is challenging. In this 24-year longitudinal single-center study, we present an algorithmic treatment approach. A retrospective analysis of 2167 patients with postintubation tracheal stenosis indicated 83 (3.83%) patients with multisegmental tracheal stenosis. Patients were assigned to 4 management groups according to the length, location, and severity of stenoses; tracheal infection/mucositis; laryngeal function; symptoms; general condition; and comorbid diseases. Type 1 (n= 13): 1-stage resection of both strictures, Type 2 (n= 6): 2-stage resection of both strictures, Type 3 (n= 40): resection of 1 stricture and nonresectional management of the other, Type 4 (n= 24): nonresectional management of both strictures. Outcomes were categorized as Good, Acceptable, or Poor. Univariate analyses for factors predictive of recurrence and outcome were performed. Follow-ups were completed in 70 (84.34%) patients (median, 22.5 months). Outcome was assessed as Good in 56 (82.35%), Acceptable in 10 (14.71%), Poor in 2 (2.94%), and mortality in 2 (2.94%) patients. The median length of airway resection was 46, 67.5, and 40 mm in Types 1-3, respectively. Only 11 (13.25%) patients had no history of tracheostomy or tracheal surgery. By univariate analysis, a shorter intubation period was associated with Good outcome (P= .017). No factors predictive of recurrence or outcome were ascertained. Multisegmental tracheal stenosis, generally caused by performing an inappropriate tracheostomy, is an iatrogenic disease that can be prevented. Although resection of both strictures may be feasible and is associated with Good results, in the majority of cases, a combination of surgical resection and non-resectional methods are sufficient to achieve Good results.

Anesthesiological considerations in emphysema surgery.

In the last decades, developing thoracic surgery raised the demands for sophisticated anesthesiological management. Especially patients with end-stage thoracic emphysema challenge the anesthesiologist to make modern surgery possible and to provide a safe and effective perioperative management. The development and scientific work-up of single lung ventilation (SLV) laid the cornerstone for surgery of the non-ventilated lung and hemi-thorax. However, modern medicine extended surgical options to extensive tracheal surgery and to patients suffering from severely insufficient lung-capacity precluding single-lung ventilation or artificial ventilation in se. For those critically ill, different techniques were thus developed and evaluated in recent research, among others, non-intubated surgery and surgery under extracorporeal perfusion support that temporarily avoids pulmonary gas exchange and ventilation via the trachea in any way. To tackle postoperative pain with its successive problems of immobilization, insufficient respiration and airway-clearance, regional anesthesia offers great advantages. Thoracic epidural anesthesia (TEA) is considered as the gold standard; complementary, modern ultrasound techniques make regional anesthesia possible even when contraindications prohibit neuraxial blocks. Especially paravertebral block, musculus serratus anterior block, intercostal block and the musculus erector spinae block provide good postoperative pain relief and appear to influence chronic post-thoracotmy pain positively. Careful preoperative preparation, intraoperative monitoring and patient-tailored, individual perioperative management by a well-trained team ensure good results, a good survival and favorable quality of life. This article provides a brief overview over state-of-the-art techniques and future perspectives to provide anesthesia in emphysema surgery.

The new frontier of tracheal surgery

The new frontier of tracheal surgery

The current status and outlook of trachea transplantation

The trachea is an enigmatic organ due to its complex morphology. Although circumferential tracheal defects are extremely difficult to repair with autologous tissue or with an allotransplant, the trachea has been touted as the first organ that could be regenerated. This review provides a comprehensive evaluation of the published evidence in tracheal tissue replacement surgery. In recent years, reports of successful tracheal regeneration have attracted great interest. Despite descriptions of the trachea as a perhaps uniquely regeneratable tissue since 2008, critical reporting provided insights into the more complex realities of tracheal regeneration attempts and led to the retraction of some articles making tracheal regeneration claims. Allotransplantation of the trachea is hindered by numerous difficult obstacles. The most promising approach developed thus far for difficult-to-repair patch airway defects is tracheal allotransplantation, which allows for tapering and withdrawal of immunosuppressive therapy. Restoration of a long-segment circumferential tracheal defect remains an unmet challenge. Future clinical studies require thoroughly documented visual evidence of outcomes to reduce confusion surrounding tracheal replacement and to prevent future scandals like those seen previously in the tracheal regeneration story. VIDEO ABSTRACT: http://links.lww.com/COOT/A6.

Multidisciplinary Approaches in Surgical Treatment and Rehabilitation of Patients with Defects of Trachea Anterior Wall

Introduction: Elimination of persistent and extensive defects of the anterior wall of the trachea is one ofthe urgent problems and continues to be the subjects of researches and discussions of the thoracic surgeons,plastic surgeons and otolaryngologists. The authors presented the results of treatment of 118 patients withextensive defects of trachea in subglottic division of the larynx and soft tissues of the neck after laryngotracheostomyor tracheostomy.Materials and Method: The authors consider that the choice of the method of plastic surgery or reconstructionof the tracheal defect is determined individually in each case. If the size of the defect of the trachea is upto 2x4 cm, the sufficient depth of the trachea lumen corresponds to the lumen above and below the stoma,the common axis of the trachea and the distal part of the larynx are without displacement and deformationof the lumen, then a skin-muscle plasty of the defect with the substitution of local tissues is recommended.Results: Local three-layer or four-layer skin-muscle plastic operations were performed in patients withdefect sizes from 1.0 sm to 2.0 sm wide and from 2.0 sm to 4.0 sm long, with a defect depth of more than8 mm, i.e. anterior-posterior size of the tracheal lumen and a stable formed lumen of the respiratory tract inthe zone of plastic contraction without the presence of a protector (T-shaped stent or tracheostomy cannula).Eleven patients with extensive defects of the anterior-lateral walls of the trachea and distal larynx underwentcomplex reconstructive operations using microsurgical techniques.Conclusion: The use of displaced flaps allows: to form a mucous membrane in the defect area withouttension of the lateral walls of the trachea (the first layer); to close the defect (or to cover the cartilaginousimplant) with a well blood-supplied second flap. A complex-compound prefabricated flap (Delta-pectoralskin-fascial-cartilaginous flap) can be used in the presence of a persistent defect and formed tracheal lumenat this level, without signs of restenosis of the respiratory tract, in the absence of inflammation and infectionof tissues around the defect. The skin-muscle-bone revascularized complexes of auto-tissues correspond allthe requirements of tracheal surgery, allowing to reduce the risk of infectious and trophic complications.

Technique of laryngotracheal resection in subglottic stenosis.

Cervical stenosis of the trachea caused by tracheotomy, tumor or induced by inflammatory disease can be treated by resection and anastomosis with good early and long-term results. Involvement of the ring cartilage makes the procedure technical demanding and increases the risk of morbidity. We describe our technique of laryngotracheal resection and reconstruction and compare the perioperative results with standard trachea resection. Between January 2005 and September 2018, we performed 92 standard cervical tracheal resections and 50 laryngotracheal resection including 6 procedures with widening of the ring cartilage. The resections were realized by direct anastomosis using dorsal flaps and/or interposition of rib cartilage in the posterior part of the ring cartilage. In one case intraoperative tracheotomy and intralaryngeal stenting was used. Patient records have been analyzed for perioperative data retrospectively. The main cause for stenosis or defect of the trachea and operation is preceding tracheotomy. Idiopathic stenosis, tumors and subglottic stenosis in Wegener disease are less common. Healing of the anastomosis was not disturbed in any patient. In two patients, bronchoscopic resection of granulation tissue was necessary. Tracheotomy in the course of treatment for intralaryngeal swelling or recurrent nerve palsy was necessary in 3 patients including one intraoperative tracheotomy for glottic stenting. Postoperative tracheostomy was closed in all patients within 3 months. Pulmonary complications and persistent recurrent nerve palsy occurred in 4 and 2 of the patients, respectively. Two patients died of pulmonary complications. The laryngotracheal resection is a relevant part of cervical tracheal surgery. It can be performed without significant elevated morbidity and is able to restore lung function and quality of voice.

Indications and postoperative outcomes of surgery for laryngotracheal stenosis: A descriptive study

ObjectiveTracheal reconstruction is a rare surgical procedure and the actual incidence of or indications for this procedure have not been thoroughly elucidated. We performed the nationwide database analysis to clarify the real-world situation of laryngotracheal surgery requiring cervical tracheal reconstruction. MethodsPatients who underwent surgical treatment for laryngotracheal stenosis or defect from 2008 to 2016 were identified from the Diagnosis Procedure Combination inpatient database, collected from 270 acute care hospitals in Japan. Patients were divided into two groups based on presence/absence of malignancy, and T-tube or tracheotomy dependence at 6 months after surgery was compared between the two groups. ResultsOne hundred and thirty-four patients (75 males) were identified. The median age at surgery was 65.5 years. The most common indication for surgery was malignancy (n = 60, 44.8%), followed by iatrogenic (n = 25, 18.6%), trauma (n = 6, 4.5%), malformation of the larynx and trachea (n = 6, 4.5%), and chronic inflammatory disease (n = 4, 2.8%). Thyroid cancer was the most common malignancy (n = 38). Thirty patients (22.4%) failed to decannulate within 6 months and malignancy was associated with a lower dependence on T-tube or tracheotomy at 6 months after surgery (adjusted odds ratio: 0.25, 95% confidence interval: 0.08–0.79). ConclusionA Japanese health insurance claims database provided a useful overview of the clinical features and outcomes of patients who underwent cervical tracheal reconstruction surgery for laryngotracheal stenosis or defect.

Chapter review – Tracheal and bronchial surgery: High jet frequency ventilation

Chapter review – Tracheal and bronchial surgery: High jet frequency ventilation

Tracheal surgery: still a challenge or a reality for thoracic surgeons?—A 30 months single-centre experience

Tracheal surgery: still a challenge or a reality for thoracic surgeons?—A 30 months single-centre experience

Endotracheal tube complication during extubation following surgical repair of a traumatic tracheal laceration

Difficult or impossible tracheal extubation has previously been reported in the veterinary literature as a result of endotracheal tube (ETT) faults or due to their entanglement with oesophagostomy tubes. Inadvertent...

Anesthesia for resection of the trachea without its intubation

Introduction. Currently, there is a tendency for a number of post-intubation patients to develop post-tracheostomic cicatricial stenosis of the trachea. This dictates a need for the improvement of surgical and anaesthesiologic approaches to intubation management. Objective: Analysis of the specific parameters of anesthesia for cervical tracheal resection in patients with stenosis of the trachea without its intubation.Subjects and methods. We analyzed 12 cases of circular resection of the trachea due to benign stenosis. The degree of anesthetic risk was as follows: 11 patients – ASA 3, 1 patient – ASA 4. Tracheal stenosis persisted for 14±6 months before it was resected (Me 4, Min 1, Max 67). The length of the resected part of the trachea was 27±3 mm (Me 25, Min 15, Max 40), duration of surgery – 159±9 min (Me 160, Min 65, Max 240). The anesthesia strategy included the insertion of the I-Gel supraglottic airway device with a jet ventilation catheter put through the I-Gel. Temporary stenting of the stenosis zone of the trachea before surgery (if necessary) instead of bougienate was an important component of the anesthesia strategy. Mandatory use of sedation (dexmedetomidine) is suggested before and within 12 hours after surgery.Results. This strategy can be successfully implemented if the minimum diameter of the tracheal stenosis exceeds 7 mm (the jet ventilation catheter is necessary to be applied through this lumen and a fine bronchoscope used to monitor the state of the catheter tip). Preliminary stenting with metal stents was performed in 5 patients. The I-Gel lumen was wide enough to manipulate a flexible endoscope, a catheter guide was inserted for jet ventilation, and then the catheter itself was placed. The use of high-frequency ventilation mask it advisable to ensure adequate gas exchange at all stages of the surgery. Sedation with dexmedetomidine reduced the patient’s discomfort after the surgery due to the fixation of the patient’s head with stitches in a “nodding” position, which reduced anastomosis tension. In all 12 patients, this anesthesia strategy was successful and provided a more favorable environment for surgeons compared to the classical approach with the use of an endotracheal tube. In all patients, anastomosis healed by primary tension with no complications.Conclusion. The use of a supraglottic airway device, dexmedetomidine, and temporary stenting of the stenotic part of the trachea allow the surgeon to avoid tracheal intubation during circular resection and expand the range of anesthesiological tools during tracheal surgery.

Databases in tracheal diseases

During the last two decades surgery has considerably changed not only under the pressure of technological advances but also for the wide dissemination of a clinical practice based on the data driven approach. In fact, surgeons became increasingly used to analyze and to review their own result in order to optimize the subsequent clinical management with the aim of offering a better quality of care to their patients. Obviously, this virtuous process must be founded on reliable and comprehensive collections of clinical data. The detailed storage of information about patients, treatments and results is even more important for those categories of disease that are less common and where the standardization of practice is poor. Tracheal diseases submitted to surgical treatment are indeed rare and the description of different aspect of clinical practice is fragmented within the scientific literature. For this reason, the needs exist of a standardized and shared data repository with a multi-institutional and international connotation that could represent a benchmark for collecting data about tracheal diseases surgery and at the same time a valuable instrument for improving the quality of care in this field.

Tracheal surgery in Germany

: First attempts of tracheal surgery in Germany were made in 1881 and tracheal resection was performed in dogs. First experiences in tracheal for malignant tracheal stenosis with tracheal resection and end-to-end anastomosis in humans were published in 1915 by the same surgeons. In 20th century several techniques of tracheal mobilisation and coverage of the anastomosis were developed to enable sufficient end-to-end anastomosis. Uniportal thoracoscopic techniques and extracorporal membrane oxygenation are progresses established more or less recently in the last decade. We performed a literature research in PubMed concerning tracheal surgery and evaluated data from the “Federal Statistical Office Germany”. In the later we requested extraction of data from the German diagnosis-related-groups (G-DRG)-system database concerning procedures and diagnoses affecting tracheal resection and management of tracheal injury. In 2018 in Germany, 267 patients were treated for neoplasm of the trachea and 66 patients for tracheal injury of the pars thoracica. Acquired tracheal stenosis was diagnosed in 1070 patients and tracheal stenosis after medical intervention in 740 individuals. There was no distinct difference in the number of cases of these diagnoses between 2014 and 2018. The most common tracheal operation in Germany is the closure of tracheostoma, which was performed almost 5,000 times per year between 2014 and 2018. Treatment of tracheal stenosis was mainly bronchoscopic. Most frequent method was the dilatation of the stenosis without implantation of a stent in 314 cases, followed by bronchoscopic excision of tissue in 119 patients. Surgical management consisted of resection of tracheal stenosis with end-to-end anastomosis in 72 cases in 2018. Management of tracheal neoplasm was with multimodal predominantly. The management of tracheal diseases is predominately performed by bronchoscopic procedures. This affects the diagnostic procedures, as well as the therapeutic interventions. It is conspicuous that there is a lack between the number of encoded diagnoses in every field of tracheal diseases and the number of encoded diagnostic and therapeutic procedures. The reason for this circumstance is unclear.

High-flow apnoeic oxygenation delivered by LMA or tracheal tube for tracheal resection and reconstruction surgery

High-flow apnoeic oxygenation delivered by LMA or tracheal tube for tracheal resection and reconstruction surgery

Primary tracheal synovial sarcoma: a rare clinical entity with diagnostic challenges

BackgroundThe incidence of primary tracheal tumors is very low. Tracheal synovial sarcoma (SS) is even an extremely rare entity. Diagnosis of tracheal SS can be achieved with chromosomal translocation studies along with immunohistochemistry. Margin-free resection is the gold standard treatment.Case presentationWe report a case of tracheal SS, which presented with stridor with a history of chronic cough and was diagnosed with a battery of clinical investigations and managed successfully with tracheal resection surgery. In histology, it may mimic Ewing’s sarcoma. Immunohistochemically, SS stains positive for cytokeratin, epithelial membrane antigen, vimentin, and S100. Chromosomal translocation t(X;18) (p11;q11) is found in almost all SS. This genetic signature is the gold standard diagnostic modality for these tumors.ConclusionDiagnosis of tracheal synovial sarcoma is challenging because of the rarity of the disease and common presenting symptoms to other tracheal pathology and is supplemented with chromosomal translocation study along with histopathology and immunohistochemistry. Tumor coring before definite surgical resection facilitates lung perfusion in obstructive tracheal pathology. A multidisciplinary team approach for diagnosis and management along with long-term follow-up are warranted.

Tracheal Reconstruction Surgery Supported by Extracorporeal Membrane Oxygenation for Patients with Traumatic Post-Tracheotomy Tracheal Stenosis

Purposes: Patients who require surgeries for traumatic post-tracheotomy tracheal stenosis (PTTS) often cannot be supported using conventional airway management approaches. This study documents the use of extracorporeal membrane oxygenation (ECMO) in patients with PTTS.Methods: Patient characteristics, procedure, and outcome of patients who required tracheal reconstruction surgery for PTTS supported by ECMO were retrieved and analyzed.Results: Four patients (mean age 28 years; range 17–48 years) with traumatic PTTS underwent tracheal reconstruction surgery supported by ECMO. The mean time from removal of tracheotomy tube to admission was 3.2 months (range: 1–9 months). The mean diameter of the stenotic segment was 5 mm (range: 4–6 mm). One patient underwent tracheoplasty and semi-tracheostomy with venoarterial ECMO urgently. Three patients underwent tracheal resection and end-to-end anastomosis (TRE) with venovenous ECMO empirically. Intervention success was achieved in 100% (4/4) of patients. The mean duration of ECMO was 35.3 hours (range: 16–53 hours). The overall survival rate was 100% (4/4) within a mean follow-up of 26 months (range: 7–57 months).Conclusions: ECMO is a safe and feasible method to support oxygenation for patients with critical traumatic PTTS during tracheal reconstruction surgery.

Etiology, diagnosis and treatment of cicatricial tracheal stenosis

Development of tracheal surgery was associated with introduction of fundamentally new procedures: two-level reconstruction, redo tracheal resection, tracheal resection with simultaneous dissection of tracheoesophageal fistula. There are combined and staged techniques when tracheal repair or endoscopic interventions are performed as a stage before circular resection of trachea. However, a single algorithm for prevention and correction of postoperative complications is still absent in tracheal surgery. Further development of tracheal surgery directly depends on introduction of preventive measures and analysis of adverse factors associated with increased risk of complications. In this regard, ongoing researches in this area are very perspective.

Management of post-intubation subglottic stenosis with individualised homoeopathic therapy: A case report

Introduction: Subglottic stenosis is a narrowing of the airway just below the vocal cords. This narrowing can cause serious breathing difficulties. Subglottic stenosis can be congenital or acquired. Frequent or long-term intubation is the most common cause of acquired subglottic stenosis. Case Summary: In this case report, adjuvant homoeopathic treatment helped prevent tracheal stent implantation surgery, otherwise deemed necessary in such a state and improved the overall general state. This case report gives ground to further investigate the extent to which individualised Homoeopathy may be applied in postintubation subglottic stenosis.