Tracheal Resection and Reconstruction



Tracheal Resection and Reconstruction


Alexander T. Hillel

William Grist





DIFFERENTIAL DIAGNOSIS



  • Tracheal stenosis is primarily due to postintubation injury, although autoimmune disease can also cause subglottic stenosis. Acquired stenosis is usually secondary to pathogenic wound healing, with the formation of permanent scar tissue in the airway.


  • Tracheal neoplasms, including adenoid cystic and squamous cell carcinoma, or thyroid tumors with tracheal invasion are less frequent etiologies for segmental tracheal or cricotracheal resection.1


PATIENT HISTORY AND PHYSICAL FINDINGS



  • A thorough history should be performed, including past medical history, past surgical history—including previous intubations or surgery on the trachea or esophagus, medications, allergies, and a family history of autoimmune disease.


  • Patients with an idiopathic etiology, who have not undergone intubation, or those with a history/family history of autoimmune disease should have an autoimmune serum panel.


  • A detailed medical history for comorbidities that could affect recovery following resection includes diabetes, coronary artery disease, and lung disease including chronic obstructive pulmonary disease (COPD) and tracheobronchial malacia. Severe COPD and tracheobronchial malacia may necessitate the need for tracheostomy even following successful resection.


  • Patients who had multiple previous procedures, especially open tracheostomies or cervical tracheoesophageal fistula repair, may have extratracheal fibrosis, making dissection more challenging and increasing the risk of injury to the recurrent laryngeal nerve (RLN).


  • Thorough evaluation of vocal fold mobility is recommended to document preoperative function. Patients often have multiple levels of stenosis, and glottic narrowing due to a second stenosis at level of vocal folds (relative contraindication) may limit the efficacy of successful tracheal resection.


  • Accurate understanding of the length of stenosis will impact the necessity of surgical release maneuvers. These are rarely required for stenosis less than 5 cm.


  • Contraindications for tracheal resection are listed in Table 1.








Table 1: Absolute and Relative Contraindications for Tracheal Resection







  1. Active autoimmune diseases affecting the airway (Wegener’s granulomatosis, relapsing polychondritis)



  2. Stenosis extending to include the vocal folds



  3. Stenosis greater than half the length of the trachea (relative contraindication)



  4. Concurrent laryngeal stenosis (relative contraindication)—tracheostomy will need to remain in place until laryngeal stenosis is addressed.



IMAGING AND OTHER DIAGNOSTIC STUDIES



  • Bronchoscopy is required to accurately map out the stenosis, including its length, width, and distance from the vocal folds and carina when appropriate. Bronchoscopy is usually performed in the operating room or endoscopy suite (FIG 1); however, with appropriate topical anesthesia, in-office bronchoscopy can provide similar results and avoid a trip to the operating room.


  • As detailed in the preceding section, laryngoscopy or stroboscopy, when indicated, should be performed to assess preoperative vocal fold mobility and the presence of laryngeal stenosis.


  • Computed tomography (CT) can provide key anatomic detail of the trachea, especially of the external trachea and adjacent vasculature. Three-dimensional CT provides excellent reconstructions of the tracheal and bronchial airways (FIG 2).


  • If the patient complains of dysphagia, a modified barium swallow study may yield relevant results especially if the patient requires infra- or suprahyoid laryngeal release maneuvers, which will adversely affect swallowing postoperatively.


SURGICAL MANAGEMENT


Preoperative Planning



  • When relevant, preoperative discussion between surgical teams about the extent of the stenosis is recommended. If the otolaryngologist represents the primary surgeon and repair of the stenosis may require a sternotomy, thoracic surgery should be consulted.



  • Similarly, if it is a primary thoracic team performing surgery and the stenosis requires a suprahyoid release maneuver, preoperative inclusion of otolaryngology team is recommended.


  • Use of an NINTM RLN monitoring endotracheal tube (ETT) is recommended to allow for monitoring of the RLN during dissection.


  • Having a second anesthesia circuit in a sterile sleeve allows for easy control of the airway when the anode tube is placed in the distal trachea following the tracheal cuts.






FIG 1 • Bronchoscopic view of tracheal stenosis taken at the level of the vocal folds.






FIG 2 • Three-dimensional sagittal CT image of cervical tracheal stenosis with dilated segment proximal to stenosis.


Positioning



  • An inflatable shoulder roll should be inflated to provide complete neck extension and deflated prior to closure.


  • Initial bronchoscopy may be performed with the bed rotated 90 degrees from the anesthesia team to allow the surgical team to dilate the stenosis in order to place an ETT.


  • Following intubation, the bed should be rotated another 90 degrees to have the head 180 degrees from anesthesia. This allows for adequate room around the head and neck.


  • If tracheostomy tube cannot be replaced with placement of an ETT following dilation, replace the tracheostomy tube with an anode tube to remove the flange from the operative field.



Jul 24, 2016 | Posted by in GENERAL | Comments Off on Tracheal Resection and Reconstruction

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