Surgical Management of Extensive Tracheal Lesions Kenneth P. Ramming, MD, Los Angeles, California Jack A. Roth, MD, Los Angeles, California Donald G. Mulder, MD, Los Angeles, California
The management of long obstructing lesions of the trachea is controversial. The use of staged reconstruction [I], prosthetic materials [2], tracheoplasty with free skin grafts [3], cryotherapy [4], repeated dilations [.5], and segmental tracheal resection [6-81 has been advocated. Recently, we treated four patients with lengthy obstructing tracheal lesions causing stridor and respiratory distress. Despite the large tracheal defect created by resection of the lesions, an end-to-end anastomosis was successfully accomplished in each instance. As a result of this experience a uniform approach for the operative management of such extensive lesions has evolved. Case Reports Case I. A 42 year old white man had a 30 pack year history of smoking. One year before admission he noted mild dyspnea with exertion, and 3 months before admission he noted that he could not catch his breath after swimming or moderate exercise. A diagnosis of trachea bronchitis was made elsewhere and he was treated with antibiotics, bronchial dilators, and expectorants, without improvement. He continued to have increased respiratory difficulty, with occasional stridor. He was seen at this institution and X-ray films revealed compression of the lower trachea on the right side. Mediastinal tomograms revealed the lower one-third of the trachea to be markedly narrowed to less than 30 per cent of the normal diameter. Computerized axial tomography of the thorax revealed a smooth, retrotracheal mass on the right, beginning approximately 1 cm below the sternal notch with maximum narrowing of the trachea occurring in the mid- and lower portion of the trachea. Pulmonary functions confirmed the obvious clinical picture of an obstructed airway with a forced expiratory volume in 1 second 43 per cent of the predicted value, maximum voluntary ventilation 30 per cent of preFrom the Department of Surgery, University of California Medical Center, Los Angeles, California. Reprint requests should be addressed to Kenneth P. Ramming, MD, Department of Surgery, Divisions OncologyIThoracic Surgery, UCLA School of Medicine, 924 Westwood Blvd, Los Angeles, California 90024. Presented at the 50th Annual Meeting of the Pacific Coast Surgical Association, Yosemite National Park, California, February 19-22. 1979.
dieted, vital capacity 11 per cent, and total lung capacity 113 per cent of the predicted values. After slow, prolonged induction of anesthesia, bronchoscopy was performed, which showed on inspiration near-total occlusion of the mid-trachea by this intrinsic polypoid exophytic lesion. No biopsy was performed, but the final pathologic diagnosis of the excised tumor was adenoid cystic carcinoma of the trachea. With the patient in the supine position, a collar incision and partial median sternotomy were performed with extension into the right chest in the fourth intercostal space. The trachea was mobilized from the great vessels and divided distally. Because of the proximity to the tracheal bifurcation, only the left main bronchus was intubated. It was necessary to resect over 7 cm of the trachea, which included eight tracheal rings. The pulmonary ligament on the right side was divided, and the right pulmonary, pericardial, and hilar attachments were incised so that the lung could be mobilized upward as much as possible. The head was flexed to provide additional proximal tracheal length. 2-O Tycron@ traction stay sutures were placed from two rings above to two rings below the anastomosis. The anastomosis was fashioned with interrupted 3-O Tycron and the stay sutures were tied to relieve tension on the anastomosis. To maintain anterior cervical flexion, the head was fixed to a supporting halo and metallic frame, which was then included in a plaster cast. This was removed on the 4th postoperative day, and the patient was discharged on the 10th postoperative day, with complete relief of his airway obstruction. He subsequently received irradiation because of known residual tumor at the upper margin of the resection.
Case II. A 55 year old white man had a long history of chronic restrictive lung disease and chronic heart disease. During treatment for acute congestive heart failure, intubation and positive pressure ventilatory support was necessary for approximately 30 hours. He recovered from this episode, but 2 months later returned with stridor, cyanosis, and severe respiratory insufficiency. The resting partial pressure of carbon dioxide was 60, pH 7.39, and partial pressure of oxygen 82. Mediastinal tomography revealed a stenotic lesion in the upper mid-trachea. At bronchoscopy a very tight fibrotic stenosis was noted. A biopsy was consistent with chronic granulation tissue. Dilation with a
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leather-tipped bougie was possible to a size 18. Within 10 days the patient was again symptomatic and repeat dilation provided relief for only 7 days. He was explored in the supine position through a transverse cervical incision. However, to achieve adequate mobilization and control it was necessary to perform a partial median sternotomy. The lesion, consisting of four tracheal rings, was resected. Severe cervical osteoarthritis and kyphosis precluded much neck flexion, but the right hilum of the lung was fully mobilized. Aided by the placement of stay sutures, an endto-end anastomosis was performed, and the maximum cervical flexion possible was maintained by suturing the chin to the anterior chest. He was discharged on the 1 lth postoperative day with complete relief of cyanosis and stridor, and marked improvement in measured pulmonary function as indicated by his flow volume loop. Case III. A 26 year old man who was an insulin-dependent diabetic with a history of many episodes of ketoacidosis was admitted to the hospital in diabetic coma and hypotensive from an acute myocardial infarction. He received int,ensive medical management, including intubation, subsequent tracheostomy, and ventilatory assistance for almost 4 months. When attempts were made to remove his tracheostomy tube, respiratory distress and stridor developed. Tracheal tomography revealed a severe obstruction of the upper trachea distal to the end of the indwelling Silastic tracheostomy tube. An inflamed constricting area distal to the tracheostomy tube was noted on bronchoscopy, and biopsy of this was consistent with necrotizing tracheitis. Two unsuccessful attempts were made to dilate the constriction. Shortly after the second attempt at dilation, the patient had a respiratory arrest and required traumatic reinsertion of the tracheostomy tube. Operation was advised and exposure of the lesion was achieved through a transverse cervical incision and partial sternotomy. The stricture, which at the time of bronchoscopy had been found to be 18 cm from the incisor teeth, was excised and end-to-end anastomosis was performed. Traction sutures were used to minimize tension on the anastomosis. A flexible, adjustable head support was used to maintain cervical flexion. His postoperative course was entirely unremarkable and follow-up bronchoscopy 3 months later revealed the trachea to be healed without restenosis. Case IV. A 55 year old white man sustained blunt trauma to the chest and sternum, requiring tracheostomy and positive pressure ventilation for 1 month. He was gradually weaned off the respirator and the tracheostomy tube was removed. Three years later he had the gradual onset of stridor with exertion, which progressed slowly over the next 2 l/1 years. Three months before admission (6 years after the injury), he developed severe respiratory distress with inspiratory and expiratory stridor at rest. The lesion was located on bronchoscopy to be 4 cm below the vocal cords, and its position and extent were confirmed by tracheal tomography. At operation through a transverse collar incision, resection of a 3 cm segment of trachea was performed. Histologically the tissue was consistent with
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squamous metaplasia and submucosal scarring. Stay sutures were used to minimize tension at the anastomosis,
which was constructed
with :1-OTycron. His postoperative
course was accompanied initially by hoarseness, but. this had resolved by the time of discharge on the 14th postoperative day.
Results All patients had an uncomplicated postoperative course and left the hospital with gratifying subjective and objective improvement in respiratory function. The first patient returned after several grand ma1 seizures 3 months later, and was found to have an intracerebral mass. The presumed diagnosis was brain metastases. During the course of his work-up he died suddenly, and at autopsy was found to have a brain abscess. It is conceivable that seeding occurred from the area of the anastomosis, although at autopsy no mediastinal abscess or mediastinitis was found. There was no evidence of tumor metastasis. The second patient developed mild symptoms of recurrent tracheal obstruction at months 2 and 4. At bronchoscopy he was found both times to have soft granulation tissue formed around exposed suture material. The suture material was removed and he
Figure 1. Mediastinal tomogram of the patient described in case I. Note marked narrowing of the lower third of the trachea with leflward deviation by the right-skied tumor mass.
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has no symptoms of tracheal obstruction 9 months after resection. The third and fourth patients have remained asymptomatic 8 and 21 months after resection, respectively.
Operative
Important of patients
Considerations
concerns in the operative management with extensive tracheal lesions are (1)
careful preoperative assessment including delineation of the precise level and extent of the lesion, (2) the detailed planning of the anesthetic management, (3) the choice of the appropriate incision, and (4) the technical considerations involved in constructing an anastomosis free of disruptive tension. 1. Preoperative Assessment. Tracheal tomography remains an invaluable radiographic method in these patients (Figure 1). It should be emphasized that the lateral view is the most helpful in deter-
Figures 2 and 3. Madtasttnal tomograms of the patient described in case Ill. Note that the obstruction below the tracheostomy tube is not apparent in the anteroposterfor projection but is obvious in the lateral projection.
Figure 4. Computerized axial tomograms of the chest of patient in case I. In the upper two scans, 2 and 3 cm below the sternal notch, the distal trachea is deformed by a solid posterior medtasttnal tumor. The esophagus is displaced laterally and compressed. In jhe lower two scans, as the cartna and azygoesophageal recess are approached, the mass is no longer present, the trachea regains its normal caliber, and the esophagus becomes apparent. Arrows labelled T and E designate the trachea and the esophagus, respectively.
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mining the distal extent of the obstruction (Figures 2 and 3), since the anteroposterior view alone may be deceptive due to the positional distortion. Computerized axial tomography added additional confirmatory information about the lesion in one of our patients (case I), but experience with this new technique is still too limited to assess its ultimate value in these problems (Figure 4). Endoscopy should be performed with caution in these airway-compromised patients. It may yield valuable information in certain patients, but trauma to the trachea in the region of the obstruction by biopsy or by attempting to pass the scope or dilating devices is extremely hazardous. 2. Anesthetic Management. The importance of a detailed plan for anesthetic management cannot be overemphasized because the ventilatory status of these patients is frequently precarious. Many will have severe underlying respiratory disease, which has been further compounded by their stenotic tracheal lesion. Careful, slow, prolonged induction is usually necessary. Recause intubation beyond the point of stenosis is usually not possible in extensive lesions, the endotracheal tube is placed just proximal to the obstruction to provide maximal ventilatory control. Should deviation from the original plan be prompted by unexpected operative findings or complications, alternative options to cope with this should be rehearsed. A wide range of sizes of endotracheal tubes with appropriate connectors and extensions should be immediately available to minimize the duration of ventilatory cessation required during distal intubation. The intraoperative manipulation of the endotracheal tubes as well as postoperative extubation will be discussed subsequently. J. Choiw of Incision. The location and extent of the lesion will determine the operative approach (Figure 5). Postintubation strictures can frequently he repaired adequately through a collar incision alone. When considerable peritracheal inflammation and scarring are present, a partial median sternotomy (performed in cases I, II, and III) will add substantially to the ease and safety of the procedure. When the distal trachea and carinal region are involved, lateral extension of the partial sternotomy into the right fourth intercostal space provides optimal and essential exposure (used in case I). This route is preferable to a lateral thoracotomy because it not only permits thorough mobilization of the pulmonary hilum but also maintains access to the neck if laryngeal release is required. d$. Anastomotic Technique. The trachea derives its blood supply from small vessels that enter at its lateral aspect. Consequently, mobilization of the
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Figure 5. Choice of incisions for exploring the trachea: ( 7) transverse cervical incision, (2) median sternotomy, and (3) median sternotomy with extension into the right chest.
trachea must be achieved by division of tissues lying in the anteroposterior plane, and circumferential dissection must be limited to the segment to be excised. It is important that the trachea be mobilized adequately, however, because the construction of a tension-free anastomosis is absolutely essential for a successful result. This is especially crucial when an unusually large defect has been created. Freeing up of the pulmonary hilum by incising pleural and pericardial attachments of hilar structures and division of the inferior pulmonary ligament, as well as releasing any tracheal adherence to the great vessels, will provide considerable mobilization of the distal segment when this is required. Caution must be exercised to avoid injury to the recurrent laryngeal nerves. Laryngeal release, that is, division of the anterior strap muscles which stabilize the larynx, may be necessary to help gain additional length to the proximal segment. A remarkable downward displacement of this segment can also be obtained by acutely flexing the neck. This facilitates performance of the anastomosis, and maintenance of the head in the flexed position once the anastomosis is constructed to avoid excess tension at the suture line is advisable for several days. This can be achieved by a chin-to-chest stitch of heavy suture material, or the use of a neck brace.
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After appropriate mobilization, the trachea is divided distal to the lesion and a sterile, flexible, cuffed endotracheal tube is inserted distally into the trachea, or in the case of distal lesions, one main stem bronchus (Figure 6). When anesthetic control is assured, resection is completed and the anastomosis
Figure 6. Sutures are placed while the distal tracheal segment is intubated. Two anterior sutures are stay sutures taken above and below the anastomosis. These are used to approximate the anastomosis while the other sutures are being tied, and then are tied themselves to relieve stress on the anastomosis.
begun. The use of relatively heavy traction stay sutures, that is, sutures taken through the trachea several rings above and below the line of anastomosis, is critical to the successful approximation of the segments without tension (Figures 6 and 7). These are eventually tied and remain as an important part of the anastomosis, although the precise approximation of the suture line is accomplished by fine interrupted Tycron or other nonabsorbable material. The posterior row of sutures is preplaced and then tied as the tracheal segments are approximated by putting tension on the stay sutures and flexing the neck. The anterior sutures are then placed but not tied until the endotracheal tube has been appropriately transferred to the desired location. In the low
Figure 7. Finished anastomosis, with tied stay sutures in place.
Figure 8. Continued uniform anterior neck flexion is maintained by this device. It can be quickly removed should reintubation be necessary in the postoperative period.
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tracheal lesions, where there is virtually no trachea distal to the repair, the previously placed oral endotracheal tube will be advanced to a point just proximal to the repair. In most other repairs of higher lesions, the endotracheal tube will be advanced under direct vision into the trachea just distal to the repair. The anterior row of sutures as well as the traction stay sutures are then tied as ventilation is resumed. The most important concern in the postoperative period is management of the airway. Early extubation is desirable, but the option for rapid reintubation must be preserved. In one patient (case I) rapid reintubation became necessary approximately 8 hours after extubation. This procedure was made quite difficult by the heavy, fixed, plaster neck stabilization device that had been applied in the operating room. Thus, it is emphasized that any such fixation device must assure a stable position but be quickly removable so that easy access for immediate intubation can be obtained. We have found a quick-release neck flexion device such as that illustrated in Figure 8 to have these features. In cases of distal post-tracheostomy stenosis where a tracheostomy is already present, leaving temporarily a small, short Silastic tracheostomy tube in place which does not extend through the anastomosis is prudent (case III). Because of the virulent nature of the bacterial flora in the upper airway, we believe that the use of antibiotics for 3 to 5 days to protect this critical anastomosis is a routine necessity, not simply a prophylactic measure. Summary
References 1. Friedman WH, Biller HF. Som ML: Repair of extended laryngotracheal stenosis. Arch Otolaryngol 101: 152, 1975.
2. Grille HC: Surgery of the trachea. Current Problems in Surgery. Chicago, Year Book Medical, 1970.
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3. ZehmS: The use of composite grafts for reconstruction of tra4.
Resection and end-to-end anastomosis has been effective in correcting localized tracheal obstruction. This procedure can be utilized in the definitive management of extensive tracheal lesions requiring the resection of at least eight tracheal rings. Important clinical considerations are the precise preoperative assessment of the lesion, careful planning of anesthetic management, choice of the appropriate incision, avoidance of circumferential dissection, and the construction of an anastomosis free of disruptive tension.
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Figure 9. Operative specimen from the patient described in case I. The trachea has been divided in saggital section. Notice that the tracheal lumen is virtually occluded by adenocystic carcinoma. Because of the extent of this lesion, it was impossible to obtain microscopically negative margins.
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5. 6. 7.
8.
chea and subglottis airway. Trans Am Acad Ophfhalmol Otolaryngol84: 934, 1977. Rodgers BM, Rosenfeld M, Talbert JL: Endobronchial ctyotherapy in treatment of tracheal strictures. J Pediatr Surg 12: 443, 1977. Hawkins DB: Glottic and subglottic stenosis from endotracheal intubation. Laryngoscope 87: 339, 1977. Webb WR, Ozdimier IA, Skins PM, Parker FB: Surgical management of tracheal stenosis. Ann Surg 179: 819, 1974. Pearson FG, Andrews MJ: Detection and management of tracheal stenosis following cuffed tube tracheostomy. Ann Thorac Surg 12: 359, 1971. Grill0 HC: Reconstruction of the trachea. Experience in 100 consecutive cases. Thorax 28: 661, 1973.
Discussion Lyman A. Brewer, III (Loma Linda, CA): The authors have presented an excellent paper and I congratulate them on their success in these f’our cases. In 1959 we presented 34 cases of tracheal and bronchial reconstruction, two of which were major tracheal resections. Since then we operated on six additional cases. Six basic principles of airway reconstruction are important: (1) a viable and functionable distal lung; (2) noncollapsing
noncicatrizing
restoration
of the airway;
(a)
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adequate oxygenation during the replacement; (4) airtight, tensionless anastomosis; (5) an adequate viable reinforcing graft; and (6) postoperative control of the secretions. Reinforcement of the tracheal graft is very important with a friable trachea, especially when the needle holes leak air. Our pedicled pericardial reinforcing fat graft permanently seals the tracheal or bronchial anastomosis as the omentum seals a bowel anastomosis in the abdomen. With the use of this graft in over 750 cases of pulmonary resection, there has been no bronchopleural fistula. In one of our early cases, a patient had extensive squamous cell carcinoma of the trachea and was literally choking to death due to severe airway obstruction. The tomogram revealed marked obstruction of most of the trachea. Subtotal tracheostomy (except for two distal rings of the trachea) and laryngectomy were performed. A permanent cervical tracheostomy was made by exteriorizing the Marlexe mesh tracheal prosthesis in the cervical region. A successful airway resulted and he breathed freely. Unfortunately, contrary to what had been previously published regarding Marlex, he was unable to raise the bronchial secretions and developed bronchiectasis. He died after a hemoptysis. This may be the most extensive tracheal-laryngeal resection ever performed. Marlex was obviously unsatisfactory. I doubt that Silastic, discussed later, would be successful. Much work needs to be done on subtotal tracheal replacement. I have told you some do’s and some don’ts. What are the best current methods? The technique of lysis of the trachea, resection, and primary union as presented by the authors is the procedure of choice. Recently, Dr. G. A. Mulder at LAC-USC Medical Center resected over one-half of the trachea with a satisfactory primary anastomosis. The chin was sewn to the anterior chest wail to hold the neck flexed. Dr. Grillo, as the result of extensive experimental studies a decade ago, has now performed tracheal resection with primary anastomosis in over 100 cases with only 4 failures. One-half of the trachea (5.5 cm) can be safely resected and primary union achieved. The case reported by the authors of resecting 7 cm of the trachea probably represents the limits of this technique. However, Dr. William Neville’s effective technique using Silastic prostheses to replace portions of the trachea and carina and both stem bronchi should be mentioned. He has performed 38 successful tracheal resections, mostly under cardiopulmonary bypass. The oldest case survived 8 years. Although we have not used this technique, others have used it successfully when tracheal and peritracheal infection make adequate mobilization impossible. Secretions are said to be “easily raised.” In summary, the technique presented is preferred providing the general principles are followed. Arthur N. Thomas (San Francisco, CA): Dr. Ramming and Dr. Brewer have reviewed the technical points about tracheal resection, and I won’t elaborate much on that. We prefer the monofilament nylon and have not seen any granulation with it.
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One point that should be emphasized is that when a patient becomes stridorous, the difference between stridor and sudden death is very small; the patient should be in the intensive care unit, and the surgeon should anticipate the: need for sudden placement of an airway. A number of patients with a cuffed tracheal tube have a tracheoesophageal fistula. One of our patients developed tracheal stenosis after the repair of the tracheal fistula, and six tracheal rings had to be resected. This was done through an incision in the neck. Most patients with the cuffed tube injury can be resected through the neck. We have not found it necessary to use a laryngeal drop. One of the reasons that reintubation should be performed in these patients in a very expeditious manner is that when a laryngeal drop is used, a cord malfunction is more likely to occur. We like to get the tubes out as early as possible. For example, in the aforementioned patient we removed the tube on the first postoperative day. All marketed low pressure cuffed tracheal tubes, which are used in over half of the patients with benign tracheal stenosis, are not really low pressure cuffed tubes. With some low pressure cuffs, you can see that the manometer is at 300 mm Hg. There is no question that the most important cause of tracheal injury is lateral wall pressure from the cuff. The tube that we prefer is the Lans@ tube, even when it is confined in something like an artificial trachea, and because of the pilot balloon it is incapable of generating pressure that will cause tracheal ischemia. Dr. Lewis and I reported a comparative series of patients in our intensive care unit who had long-term mechanical ventilation when we were using a modified Portexe tube with prestretching. Once we began using the Lans tube, we saw that most of the complications of cuffed tracheal tubes can be prevented. We recommend the use of the Lans tube. Eric W. Fonkalsrud (Los Angeles, CA): I would like to congratulate the authors on their excellent presentation. A few years ago we encountered a 2’/s year old boy with a severe stricture of the entire trachea extending from the larynx to the carina. He developed severe stridor and an emergency tracheostomy did not improve the condition. An emergency operation was performed in which the trachea was divided at the level of the carina and the esophagus anastomosed to the lower tracheobronchial tree. The upper end of the esophagus was divided and one end brought out as an esophagotracheostomy with a long Portex tube left in place for ventilation. The other end of the esophagus was constructed as a cutaneous cervical esophagostomy. This patient survived for over 3 months when he died with a large mucous plug at the esophagobronchial anastomosis. A few years ago we found that autologous periosteum may serve as a satisfactory tracheal substitute in the laboratory animal. The periosteum from a rib is folded over on itself around a Silastic tubing, and after it calcifies and becomes firm, it is rotated into the desired position of the trachea. Intercostal vascularity is necessary to maintain
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a rigid tube since free per&teal grafts did not calcify or function adequately. I would like to ask Dr. Ramming how he manages the problem of removing secretions after the tracheal anastomosis is performed under tension and how he avoids dependent pneumonia. Have there been leaks that resulted after the anastomosis was performed? Roger Raymond Ecker (Oakland, CA): About 15 years ago we did some work in dogs trying to develop a prosthesis for the esophagus and the trachea. The problems that we encountered of stricture and infection at the site of the anastomosis and eventual extrusion of the prosthesis, with occasional erosion of the great vessels, made it very discouraging. I agree with Dr. Ramming and his associates that primary anastomosis is the treatment of choice. When the lesion is radiosensitive and if there is not too much obstruction of the trachea when the patient is first seen, you can often limit the length of resection necessary by giving preoperative irradiation. Approximately 3,000 rads to the area will limit the extension of the tumor and make your margins clearer. In the anesthetic management, if you are going to intubate one main stem bronchus you should insert an arterial line to check the blood saturation. If it goes down because one lung is perfused but not ventilated, then it is advisable, of course, to temporarily occlude the pulmonary artery to that side. In some patients, when you collapse the lung the circulation to that lung also decreases automatically. It is not predictable which patients are going to require temporary occlusion of the pulmonary artery. One patient, an alcoholic and a heavy smoker, had a carcinoma of the lower trachea right on the carina. The resection was about 5 cm long and the lesion was a squamous carcinoma. We did not use long stay sutures, but we freed up the main stem bronchi so that there was no tension when the sutures were tied. The completed anastomosis was covered with adjacent tissue. The patient is now alive and without recurrence 2 years later. I would like to congratulate the authors on their technique. We still have the problem of what to do when the lesion is longer than this technique permits. There is no good answer to that at present, and probably in the future prostheses will be the only answer for these longer lesions. Ivan A. May (Oakland, CA): Ten years ago we saw a few patients with tracheal stenosis, which we felt was due to the pressure caused by the endotracheal or tracheostomy tube cuff. Working with dogs (Shelly WM, Dawson RB, May IA: Cuffed tubes as a cause of tracheal stenosis. J Thorac C’ardiooasc Surg 57: 623,1969), we found that when a cuff was distended with the minimum amount of air to prevent a leak, no stenosis was caused even when the cuff was left up continuously for 5 days. When 2 times the minimum occluding volume was used, almost all dogs developed
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strictures. We decided that rather than having whoever was attending the patient let the cuff down every hour as was the custom at that time, it was better to leave it up continuously and check it once a day ourselves. Subsequently low pressure cuffs have been developed that minimize the problem. At that time we found that an early stricture could be controlled by frequent dilatation, but a fixed stricture could not be dilated and some type of resection or plasty was required. One patient of Ken Hardy (my late partner) is a professional singer. He developed a stricture due to prolonged respiratory support by a cuffed tracheostomy tube after a cardiac operation in 1970. When we first saw him in 1971 his trachea was completely occluded above the tracheostomy. We resected the stricture a couple of limes, but it recurred. It did not respond to daily dilatations for several months. Ken then designed a stint which he put inside the upper trachea with a central lumen for breathing. It was held in place by a string brought out the tracheostomy tube site. Healing occurred around the stint and string, which were left in for about 6 months. The stint was removed by bronchoscopy in 1973. The stricture has not recurred. We agree with the authors that the best way to keep track of these strictures is by laminograms. This man’s stricture has been laminogrammed periodically and has not changed in 6 years. He is singing again on a weekly television show. His phrases are a little short because of slightly restricted inspiration. but he still sings. Donald Mulder (closing): I appreciate Dr. Lyman Brewer’s comprehensive review of this problem and the very pertinent questions and comments of the discussants. I will briefly respond to some of the many questions that have been raised. In regard to using the fat graft, Dr. Brewer, we haven’t felt that necessary. Perhaps we use smaller diameter needles that don’t seem to leak as much, but I am sure that would be useful when the bronchial anastomosis is tenuous. I am concerned about the use of prosthetic tubes. I know Dr. Neville had some successful results, but. many have failed, and the failure of this anastomosis is usually a catastrophe. So I think we need to be quite confident that the operation being performed has a high probability of success. One question always comes up. What do you do, if, after resecting an excessive amount of tumor, you can’t get the two ends together? Dr. Fonkalsrud showed an interesting and unusual way to manage this. Another technique that our head and neck surgeons have advocated in the unusual circumstance mentioned is to resect part of the upper sternum and turn down a full thickness skin flap to the margin of the distal trachea, which makes a very suitable tracheal orifice. Dr. Thomas pointed out very appropriately how tenuous these patients are, and that the difference between stridor and a catastrophic obstruction is a small one. Prompt relief of the obstruction is mandatory.
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Several have mentioned the appropriateness of avoiding tracheal strictures by proper intubation and management of the endotracheal tube. We certainly agree that an ounce of prevention is worth many pounds of cure. Dr. Fonkalsrud wondered whether suctioning the patients is hazardous. I think we all agree that marking the endotracheal suction catheter at the appropriate length well short of the anastomosis is a good idea. We have not had problems with persistent air leak or difficulty with suctioning these patients. Dr. Ecker makes the good point that irradiation of some of these lesions as long as they are not critically obstructing
aa
may well shrink them to the point where resectional therapy is more likely to be successful. He also points out quite appropriately that radial artery monitoring of arterial gases is helpful when one is intubating only one bronchus. In this way intrapulmonary shunting can be detected and the appropriate occlusion of the ipsilateral pulmonary artery can be performed. And finally, Dr. May, we also agree that prevention of these strictures by avoidance of high pressure cuffs on the endotracheal tubes is possible and constant attention to proper tube management is crucial. I appreciate all the interest that this paper has generated and thank the discussants for their comments.
The American Journal of Surgery
The management of long obstructing lesions of the trachea is controversial. The use of staged reconstruction [I], prosthetic materials [2], tracheoplasty with free skin grafts [3], cryotherapy [4], repeated dilations [.5], and segmental tracheal resection [6-81 has been advocated. Recently, we treated four patients with lengthy obstructing tracheal lesions causing stridor and respiratory distress. Despite the large tracheal defect created by resection of the lesions, an end-to-end anastomosis was successfully accomplished in each instance. As a result of this experience a uniform approach for the operative management of such extensive lesions has evolved. Case Reports Case I. A 42 year old white man had a 30 pack year history of smoking. One year before admission he noted mild dyspnea with exertion, and 3 months before admission he noted that he could not catch his breath after swimming or moderate exercise. A diagnosis of trachea bronchitis was made elsewhere and he was treated with antibiotics, bronchial dilators, and expectorants, without improvement. He continued to have increased respiratory difficulty, with occasional stridor. He was seen at this institution and X-ray films revealed compression of the lower trachea on the right side. Mediastinal tomograms revealed the lower one-third of the trachea to be markedly narrowed to less than 30 per cent of the normal diameter. Computerized axial tomography of the thorax revealed a smooth, retrotracheal mass on the right, beginning approximately 1 cm below the sternal notch with maximum narrowing of the trachea occurring in the mid- and lower portion of the trachea. Pulmonary functions confirmed the obvious clinical picture of an obstructed airway with a forced expiratory volume in 1 second 43 per cent of the predicted value, maximum voluntary ventilation 30 per cent of preFrom the Department of Surgery, University of California Medical Center, Los Angeles, California. Reprint requests should be addressed to Kenneth P. Ramming, MD, Department of Surgery, Divisions OncologyIThoracic Surgery, UCLA School of Medicine, 924 Westwood Blvd, Los Angeles, California 90024. Presented at the 50th Annual Meeting of the Pacific Coast Surgical Association, Yosemite National Park, California, February 19-22. 1979.
dieted, vital capacity 11 per cent, and total lung capacity 113 per cent of the predicted values. After slow, prolonged induction of anesthesia, bronchoscopy was performed, which showed on inspiration near-total occlusion of the mid-trachea by this intrinsic polypoid exophytic lesion. No biopsy was performed, but the final pathologic diagnosis of the excised tumor was adenoid cystic carcinoma of the trachea. With the patient in the supine position, a collar incision and partial median sternotomy were performed with extension into the right chest in the fourth intercostal space. The trachea was mobilized from the great vessels and divided distally. Because of the proximity to the tracheal bifurcation, only the left main bronchus was intubated. It was necessary to resect over 7 cm of the trachea, which included eight tracheal rings. The pulmonary ligament on the right side was divided, and the right pulmonary, pericardial, and hilar attachments were incised so that the lung could be mobilized upward as much as possible. The head was flexed to provide additional proximal tracheal length. 2-O Tycron@ traction stay sutures were placed from two rings above to two rings below the anastomosis. The anastomosis was fashioned with interrupted 3-O Tycron and the stay sutures were tied to relieve tension on the anastomosis. To maintain anterior cervical flexion, the head was fixed to a supporting halo and metallic frame, which was then included in a plaster cast. This was removed on the 4th postoperative day, and the patient was discharged on the 10th postoperative day, with complete relief of his airway obstruction. He subsequently received irradiation because of known residual tumor at the upper margin of the resection.
Case II. A 55 year old white man had a long history of chronic restrictive lung disease and chronic heart disease. During treatment for acute congestive heart failure, intubation and positive pressure ventilatory support was necessary for approximately 30 hours. He recovered from this episode, but 2 months later returned with stridor, cyanosis, and severe respiratory insufficiency. The resting partial pressure of carbon dioxide was 60, pH 7.39, and partial pressure of oxygen 82. Mediastinal tomography revealed a stenotic lesion in the upper mid-trachea. At bronchoscopy a very tight fibrotic stenosis was noted. A biopsy was consistent with chronic granulation tissue. Dilation with a
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leather-tipped bougie was possible to a size 18. Within 10 days the patient was again symptomatic and repeat dilation provided relief for only 7 days. He was explored in the supine position through a transverse cervical incision. However, to achieve adequate mobilization and control it was necessary to perform a partial median sternotomy. The lesion, consisting of four tracheal rings, was resected. Severe cervical osteoarthritis and kyphosis precluded much neck flexion, but the right hilum of the lung was fully mobilized. Aided by the placement of stay sutures, an endto-end anastomosis was performed, and the maximum cervical flexion possible was maintained by suturing the chin to the anterior chest. He was discharged on the 1 lth postoperative day with complete relief of cyanosis and stridor, and marked improvement in measured pulmonary function as indicated by his flow volume loop. Case III. A 26 year old man who was an insulin-dependent diabetic with a history of many episodes of ketoacidosis was admitted to the hospital in diabetic coma and hypotensive from an acute myocardial infarction. He received int,ensive medical management, including intubation, subsequent tracheostomy, and ventilatory assistance for almost 4 months. When attempts were made to remove his tracheostomy tube, respiratory distress and stridor developed. Tracheal tomography revealed a severe obstruction of the upper trachea distal to the end of the indwelling Silastic tracheostomy tube. An inflamed constricting area distal to the tracheostomy tube was noted on bronchoscopy, and biopsy of this was consistent with necrotizing tracheitis. Two unsuccessful attempts were made to dilate the constriction. Shortly after the second attempt at dilation, the patient had a respiratory arrest and required traumatic reinsertion of the tracheostomy tube. Operation was advised and exposure of the lesion was achieved through a transverse cervical incision and partial sternotomy. The stricture, which at the time of bronchoscopy had been found to be 18 cm from the incisor teeth, was excised and end-to-end anastomosis was performed. Traction sutures were used to minimize tension on the anastomosis. A flexible, adjustable head support was used to maintain cervical flexion. His postoperative course was entirely unremarkable and follow-up bronchoscopy 3 months later revealed the trachea to be healed without restenosis. Case IV. A 55 year old white man sustained blunt trauma to the chest and sternum, requiring tracheostomy and positive pressure ventilation for 1 month. He was gradually weaned off the respirator and the tracheostomy tube was removed. Three years later he had the gradual onset of stridor with exertion, which progressed slowly over the next 2 l/1 years. Three months before admission (6 years after the injury), he developed severe respiratory distress with inspiratory and expiratory stridor at rest. The lesion was located on bronchoscopy to be 4 cm below the vocal cords, and its position and extent were confirmed by tracheal tomography. At operation through a transverse collar incision, resection of a 3 cm segment of trachea was performed. Histologically the tissue was consistent with
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squamous metaplasia and submucosal scarring. Stay sutures were used to minimize tension at the anastomosis,
which was constructed
with :1-OTycron. His postoperative
course was accompanied initially by hoarseness, but. this had resolved by the time of discharge on the 14th postoperative day.
Results All patients had an uncomplicated postoperative course and left the hospital with gratifying subjective and objective improvement in respiratory function. The first patient returned after several grand ma1 seizures 3 months later, and was found to have an intracerebral mass. The presumed diagnosis was brain metastases. During the course of his work-up he died suddenly, and at autopsy was found to have a brain abscess. It is conceivable that seeding occurred from the area of the anastomosis, although at autopsy no mediastinal abscess or mediastinitis was found. There was no evidence of tumor metastasis. The second patient developed mild symptoms of recurrent tracheal obstruction at months 2 and 4. At bronchoscopy he was found both times to have soft granulation tissue formed around exposed suture material. The suture material was removed and he
Figure 1. Mediastinal tomogram of the patient described in case I. Note marked narrowing of the lower third of the trachea with leflward deviation by the right-skied tumor mass.
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has no symptoms of tracheal obstruction 9 months after resection. The third and fourth patients have remained asymptomatic 8 and 21 months after resection, respectively.
Operative
Important of patients
Considerations
concerns in the operative management with extensive tracheal lesions are (1)
careful preoperative assessment including delineation of the precise level and extent of the lesion, (2) the detailed planning of the anesthetic management, (3) the choice of the appropriate incision, and (4) the technical considerations involved in constructing an anastomosis free of disruptive tension. 1. Preoperative Assessment. Tracheal tomography remains an invaluable radiographic method in these patients (Figure 1). It should be emphasized that the lateral view is the most helpful in deter-
Figures 2 and 3. Madtasttnal tomograms of the patient described in case Ill. Note that the obstruction below the tracheostomy tube is not apparent in the anteroposterfor projection but is obvious in the lateral projection.
Figure 4. Computerized axial tomograms of the chest of patient in case I. In the upper two scans, 2 and 3 cm below the sternal notch, the distal trachea is deformed by a solid posterior medtasttnal tumor. The esophagus is displaced laterally and compressed. In jhe lower two scans, as the cartna and azygoesophageal recess are approached, the mass is no longer present, the trachea regains its normal caliber, and the esophagus becomes apparent. Arrows labelled T and E designate the trachea and the esophagus, respectively.
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mining the distal extent of the obstruction (Figures 2 and 3), since the anteroposterior view alone may be deceptive due to the positional distortion. Computerized axial tomography added additional confirmatory information about the lesion in one of our patients (case I), but experience with this new technique is still too limited to assess its ultimate value in these problems (Figure 4). Endoscopy should be performed with caution in these airway-compromised patients. It may yield valuable information in certain patients, but trauma to the trachea in the region of the obstruction by biopsy or by attempting to pass the scope or dilating devices is extremely hazardous. 2. Anesthetic Management. The importance of a detailed plan for anesthetic management cannot be overemphasized because the ventilatory status of these patients is frequently precarious. Many will have severe underlying respiratory disease, which has been further compounded by their stenotic tracheal lesion. Careful, slow, prolonged induction is usually necessary. Recause intubation beyond the point of stenosis is usually not possible in extensive lesions, the endotracheal tube is placed just proximal to the obstruction to provide maximal ventilatory control. Should deviation from the original plan be prompted by unexpected operative findings or complications, alternative options to cope with this should be rehearsed. A wide range of sizes of endotracheal tubes with appropriate connectors and extensions should be immediately available to minimize the duration of ventilatory cessation required during distal intubation. The intraoperative manipulation of the endotracheal tubes as well as postoperative extubation will be discussed subsequently. J. Choiw of Incision. The location and extent of the lesion will determine the operative approach (Figure 5). Postintubation strictures can frequently he repaired adequately through a collar incision alone. When considerable peritracheal inflammation and scarring are present, a partial median sternotomy (performed in cases I, II, and III) will add substantially to the ease and safety of the procedure. When the distal trachea and carinal region are involved, lateral extension of the partial sternotomy into the right fourth intercostal space provides optimal and essential exposure (used in case I). This route is preferable to a lateral thoracotomy because it not only permits thorough mobilization of the pulmonary hilum but also maintains access to the neck if laryngeal release is required. d$. Anastomotic Technique. The trachea derives its blood supply from small vessels that enter at its lateral aspect. Consequently, mobilization of the
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Figure 5. Choice of incisions for exploring the trachea: ( 7) transverse cervical incision, (2) median sternotomy, and (3) median sternotomy with extension into the right chest.
trachea must be achieved by division of tissues lying in the anteroposterior plane, and circumferential dissection must be limited to the segment to be excised. It is important that the trachea be mobilized adequately, however, because the construction of a tension-free anastomosis is absolutely essential for a successful result. This is especially crucial when an unusually large defect has been created. Freeing up of the pulmonary hilum by incising pleural and pericardial attachments of hilar structures and division of the inferior pulmonary ligament, as well as releasing any tracheal adherence to the great vessels, will provide considerable mobilization of the distal segment when this is required. Caution must be exercised to avoid injury to the recurrent laryngeal nerves. Laryngeal release, that is, division of the anterior strap muscles which stabilize the larynx, may be necessary to help gain additional length to the proximal segment. A remarkable downward displacement of this segment can also be obtained by acutely flexing the neck. This facilitates performance of the anastomosis, and maintenance of the head in the flexed position once the anastomosis is constructed to avoid excess tension at the suture line is advisable for several days. This can be achieved by a chin-to-chest stitch of heavy suture material, or the use of a neck brace.
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After appropriate mobilization, the trachea is divided distal to the lesion and a sterile, flexible, cuffed endotracheal tube is inserted distally into the trachea, or in the case of distal lesions, one main stem bronchus (Figure 6). When anesthetic control is assured, resection is completed and the anastomosis
Figure 6. Sutures are placed while the distal tracheal segment is intubated. Two anterior sutures are stay sutures taken above and below the anastomosis. These are used to approximate the anastomosis while the other sutures are being tied, and then are tied themselves to relieve stress on the anastomosis.
begun. The use of relatively heavy traction stay sutures, that is, sutures taken through the trachea several rings above and below the line of anastomosis, is critical to the successful approximation of the segments without tension (Figures 6 and 7). These are eventually tied and remain as an important part of the anastomosis, although the precise approximation of the suture line is accomplished by fine interrupted Tycron or other nonabsorbable material. The posterior row of sutures is preplaced and then tied as the tracheal segments are approximated by putting tension on the stay sutures and flexing the neck. The anterior sutures are then placed but not tied until the endotracheal tube has been appropriately transferred to the desired location. In the low
Figure 7. Finished anastomosis, with tied stay sutures in place.
Figure 8. Continued uniform anterior neck flexion is maintained by this device. It can be quickly removed should reintubation be necessary in the postoperative period.
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tracheal lesions, where there is virtually no trachea distal to the repair, the previously placed oral endotracheal tube will be advanced to a point just proximal to the repair. In most other repairs of higher lesions, the endotracheal tube will be advanced under direct vision into the trachea just distal to the repair. The anterior row of sutures as well as the traction stay sutures are then tied as ventilation is resumed. The most important concern in the postoperative period is management of the airway. Early extubation is desirable, but the option for rapid reintubation must be preserved. In one patient (case I) rapid reintubation became necessary approximately 8 hours after extubation. This procedure was made quite difficult by the heavy, fixed, plaster neck stabilization device that had been applied in the operating room. Thus, it is emphasized that any such fixation device must assure a stable position but be quickly removable so that easy access for immediate intubation can be obtained. We have found a quick-release neck flexion device such as that illustrated in Figure 8 to have these features. In cases of distal post-tracheostomy stenosis where a tracheostomy is already present, leaving temporarily a small, short Silastic tracheostomy tube in place which does not extend through the anastomosis is prudent (case III). Because of the virulent nature of the bacterial flora in the upper airway, we believe that the use of antibiotics for 3 to 5 days to protect this critical anastomosis is a routine necessity, not simply a prophylactic measure. Summary
References 1. Friedman WH, Biller HF. Som ML: Repair of extended laryngotracheal stenosis. Arch Otolaryngol 101: 152, 1975.
2. Grille HC: Surgery of the trachea. Current Problems in Surgery. Chicago, Year Book Medical, 1970.
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3. ZehmS: The use of composite grafts for reconstruction of tra4.
Resection and end-to-end anastomosis has been effective in correcting localized tracheal obstruction. This procedure can be utilized in the definitive management of extensive tracheal lesions requiring the resection of at least eight tracheal rings. Important clinical considerations are the precise preoperative assessment of the lesion, careful planning of anesthetic management, choice of the appropriate incision, avoidance of circumferential dissection, and the construction of an anastomosis free of disruptive tension.
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Figure 9. Operative specimen from the patient described in case I. The trachea has been divided in saggital section. Notice that the tracheal lumen is virtually occluded by adenocystic carcinoma. Because of the extent of this lesion, it was impossible to obtain microscopically negative margins.
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5. 6. 7.
8.
chea and subglottis airway. Trans Am Acad Ophfhalmol Otolaryngol84: 934, 1977. Rodgers BM, Rosenfeld M, Talbert JL: Endobronchial ctyotherapy in treatment of tracheal strictures. J Pediatr Surg 12: 443, 1977. Hawkins DB: Glottic and subglottic stenosis from endotracheal intubation. Laryngoscope 87: 339, 1977. Webb WR, Ozdimier IA, Skins PM, Parker FB: Surgical management of tracheal stenosis. Ann Surg 179: 819, 1974. Pearson FG, Andrews MJ: Detection and management of tracheal stenosis following cuffed tube tracheostomy. Ann Thorac Surg 12: 359, 1971. Grill0 HC: Reconstruction of the trachea. Experience in 100 consecutive cases. Thorax 28: 661, 1973.
Discussion Lyman A. Brewer, III (Loma Linda, CA): The authors have presented an excellent paper and I congratulate them on their success in these f’our cases. In 1959 we presented 34 cases of tracheal and bronchial reconstruction, two of which were major tracheal resections. Since then we operated on six additional cases. Six basic principles of airway reconstruction are important: (1) a viable and functionable distal lung; (2) noncollapsing
noncicatrizing
restoration
of the airway;
(a)
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adequate oxygenation during the replacement; (4) airtight, tensionless anastomosis; (5) an adequate viable reinforcing graft; and (6) postoperative control of the secretions. Reinforcement of the tracheal graft is very important with a friable trachea, especially when the needle holes leak air. Our pedicled pericardial reinforcing fat graft permanently seals the tracheal or bronchial anastomosis as the omentum seals a bowel anastomosis in the abdomen. With the use of this graft in over 750 cases of pulmonary resection, there has been no bronchopleural fistula. In one of our early cases, a patient had extensive squamous cell carcinoma of the trachea and was literally choking to death due to severe airway obstruction. The tomogram revealed marked obstruction of most of the trachea. Subtotal tracheostomy (except for two distal rings of the trachea) and laryngectomy were performed. A permanent cervical tracheostomy was made by exteriorizing the Marlexe mesh tracheal prosthesis in the cervical region. A successful airway resulted and he breathed freely. Unfortunately, contrary to what had been previously published regarding Marlex, he was unable to raise the bronchial secretions and developed bronchiectasis. He died after a hemoptysis. This may be the most extensive tracheal-laryngeal resection ever performed. Marlex was obviously unsatisfactory. I doubt that Silastic, discussed later, would be successful. Much work needs to be done on subtotal tracheal replacement. I have told you some do’s and some don’ts. What are the best current methods? The technique of lysis of the trachea, resection, and primary union as presented by the authors is the procedure of choice. Recently, Dr. G. A. Mulder at LAC-USC Medical Center resected over one-half of the trachea with a satisfactory primary anastomosis. The chin was sewn to the anterior chest wail to hold the neck flexed. Dr. Grillo, as the result of extensive experimental studies a decade ago, has now performed tracheal resection with primary anastomosis in over 100 cases with only 4 failures. One-half of the trachea (5.5 cm) can be safely resected and primary union achieved. The case reported by the authors of resecting 7 cm of the trachea probably represents the limits of this technique. However, Dr. William Neville’s effective technique using Silastic prostheses to replace portions of the trachea and carina and both stem bronchi should be mentioned. He has performed 38 successful tracheal resections, mostly under cardiopulmonary bypass. The oldest case survived 8 years. Although we have not used this technique, others have used it successfully when tracheal and peritracheal infection make adequate mobilization impossible. Secretions are said to be “easily raised.” In summary, the technique presented is preferred providing the general principles are followed. Arthur N. Thomas (San Francisco, CA): Dr. Ramming and Dr. Brewer have reviewed the technical points about tracheal resection, and I won’t elaborate much on that. We prefer the monofilament nylon and have not seen any granulation with it.
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One point that should be emphasized is that when a patient becomes stridorous, the difference between stridor and sudden death is very small; the patient should be in the intensive care unit, and the surgeon should anticipate the: need for sudden placement of an airway. A number of patients with a cuffed tracheal tube have a tracheoesophageal fistula. One of our patients developed tracheal stenosis after the repair of the tracheal fistula, and six tracheal rings had to be resected. This was done through an incision in the neck. Most patients with the cuffed tube injury can be resected through the neck. We have not found it necessary to use a laryngeal drop. One of the reasons that reintubation should be performed in these patients in a very expeditious manner is that when a laryngeal drop is used, a cord malfunction is more likely to occur. We like to get the tubes out as early as possible. For example, in the aforementioned patient we removed the tube on the first postoperative day. All marketed low pressure cuffed tracheal tubes, which are used in over half of the patients with benign tracheal stenosis, are not really low pressure cuffed tubes. With some low pressure cuffs, you can see that the manometer is at 300 mm Hg. There is no question that the most important cause of tracheal injury is lateral wall pressure from the cuff. The tube that we prefer is the Lans@ tube, even when it is confined in something like an artificial trachea, and because of the pilot balloon it is incapable of generating pressure that will cause tracheal ischemia. Dr. Lewis and I reported a comparative series of patients in our intensive care unit who had long-term mechanical ventilation when we were using a modified Portexe tube with prestretching. Once we began using the Lans tube, we saw that most of the complications of cuffed tracheal tubes can be prevented. We recommend the use of the Lans tube. Eric W. Fonkalsrud (Los Angeles, CA): I would like to congratulate the authors on their excellent presentation. A few years ago we encountered a 2’/s year old boy with a severe stricture of the entire trachea extending from the larynx to the carina. He developed severe stridor and an emergency tracheostomy did not improve the condition. An emergency operation was performed in which the trachea was divided at the level of the carina and the esophagus anastomosed to the lower tracheobronchial tree. The upper end of the esophagus was divided and one end brought out as an esophagotracheostomy with a long Portex tube left in place for ventilation. The other end of the esophagus was constructed as a cutaneous cervical esophagostomy. This patient survived for over 3 months when he died with a large mucous plug at the esophagobronchial anastomosis. A few years ago we found that autologous periosteum may serve as a satisfactory tracheal substitute in the laboratory animal. The periosteum from a rib is folded over on itself around a Silastic tubing, and after it calcifies and becomes firm, it is rotated into the desired position of the trachea. Intercostal vascularity is necessary to maintain
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a rigid tube since free per&teal grafts did not calcify or function adequately. I would like to ask Dr. Ramming how he manages the problem of removing secretions after the tracheal anastomosis is performed under tension and how he avoids dependent pneumonia. Have there been leaks that resulted after the anastomosis was performed? Roger Raymond Ecker (Oakland, CA): About 15 years ago we did some work in dogs trying to develop a prosthesis for the esophagus and the trachea. The problems that we encountered of stricture and infection at the site of the anastomosis and eventual extrusion of the prosthesis, with occasional erosion of the great vessels, made it very discouraging. I agree with Dr. Ramming and his associates that primary anastomosis is the treatment of choice. When the lesion is radiosensitive and if there is not too much obstruction of the trachea when the patient is first seen, you can often limit the length of resection necessary by giving preoperative irradiation. Approximately 3,000 rads to the area will limit the extension of the tumor and make your margins clearer. In the anesthetic management, if you are going to intubate one main stem bronchus you should insert an arterial line to check the blood saturation. If it goes down because one lung is perfused but not ventilated, then it is advisable, of course, to temporarily occlude the pulmonary artery to that side. In some patients, when you collapse the lung the circulation to that lung also decreases automatically. It is not predictable which patients are going to require temporary occlusion of the pulmonary artery. One patient, an alcoholic and a heavy smoker, had a carcinoma of the lower trachea right on the carina. The resection was about 5 cm long and the lesion was a squamous carcinoma. We did not use long stay sutures, but we freed up the main stem bronchi so that there was no tension when the sutures were tied. The completed anastomosis was covered with adjacent tissue. The patient is now alive and without recurrence 2 years later. I would like to congratulate the authors on their technique. We still have the problem of what to do when the lesion is longer than this technique permits. There is no good answer to that at present, and probably in the future prostheses will be the only answer for these longer lesions. Ivan A. May (Oakland, CA): Ten years ago we saw a few patients with tracheal stenosis, which we felt was due to the pressure caused by the endotracheal or tracheostomy tube cuff. Working with dogs (Shelly WM, Dawson RB, May IA: Cuffed tubes as a cause of tracheal stenosis. J Thorac C’ardiooasc Surg 57: 623,1969), we found that when a cuff was distended with the minimum amount of air to prevent a leak, no stenosis was caused even when the cuff was left up continuously for 5 days. When 2 times the minimum occluding volume was used, almost all dogs developed
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strictures. We decided that rather than having whoever was attending the patient let the cuff down every hour as was the custom at that time, it was better to leave it up continuously and check it once a day ourselves. Subsequently low pressure cuffs have been developed that minimize the problem. At that time we found that an early stricture could be controlled by frequent dilatation, but a fixed stricture could not be dilated and some type of resection or plasty was required. One patient of Ken Hardy (my late partner) is a professional singer. He developed a stricture due to prolonged respiratory support by a cuffed tracheostomy tube after a cardiac operation in 1970. When we first saw him in 1971 his trachea was completely occluded above the tracheostomy. We resected the stricture a couple of limes, but it recurred. It did not respond to daily dilatations for several months. Ken then designed a stint which he put inside the upper trachea with a central lumen for breathing. It was held in place by a string brought out the tracheostomy tube site. Healing occurred around the stint and string, which were left in for about 6 months. The stint was removed by bronchoscopy in 1973. The stricture has not recurred. We agree with the authors that the best way to keep track of these strictures is by laminograms. This man’s stricture has been laminogrammed periodically and has not changed in 6 years. He is singing again on a weekly television show. His phrases are a little short because of slightly restricted inspiration. but he still sings. Donald Mulder (closing): I appreciate Dr. Lyman Brewer’s comprehensive review of this problem and the very pertinent questions and comments of the discussants. I will briefly respond to some of the many questions that have been raised. In regard to using the fat graft, Dr. Brewer, we haven’t felt that necessary. Perhaps we use smaller diameter needles that don’t seem to leak as much, but I am sure that would be useful when the bronchial anastomosis is tenuous. I am concerned about the use of prosthetic tubes. I know Dr. Neville had some successful results, but. many have failed, and the failure of this anastomosis is usually a catastrophe. So I think we need to be quite confident that the operation being performed has a high probability of success. One question always comes up. What do you do, if, after resecting an excessive amount of tumor, you can’t get the two ends together? Dr. Fonkalsrud showed an interesting and unusual way to manage this. Another technique that our head and neck surgeons have advocated in the unusual circumstance mentioned is to resect part of the upper sternum and turn down a full thickness skin flap to the margin of the distal trachea, which makes a very suitable tracheal orifice. Dr. Thomas pointed out very appropriately how tenuous these patients are, and that the difference between stridor and a catastrophic obstruction is a small one. Prompt relief of the obstruction is mandatory.
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Several have mentioned the appropriateness of avoiding tracheal strictures by proper intubation and management of the endotracheal tube. We certainly agree that an ounce of prevention is worth many pounds of cure. Dr. Fonkalsrud wondered whether suctioning the patients is hazardous. I think we all agree that marking the endotracheal suction catheter at the appropriate length well short of the anastomosis is a good idea. We have not had problems with persistent air leak or difficulty with suctioning these patients. Dr. Ecker makes the good point that irradiation of some of these lesions as long as they are not critically obstructing
aa
may well shrink them to the point where resectional therapy is more likely to be successful. He also points out quite appropriately that radial artery monitoring of arterial gases is helpful when one is intubating only one bronchus. In this way intrapulmonary shunting can be detected and the appropriate occlusion of the ipsilateral pulmonary artery can be performed. And finally, Dr. May, we also agree that prevention of these strictures by avoidance of high pressure cuffs on the endotracheal tubes is possible and constant attention to proper tube management is crucial. I appreciate all the interest that this paper has generated and thank the discussants for their comments.
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