Development of tracheal surgery: a historical review. Part 2: Treatment of tracheal diseases

Optimization of a decellularization protocol of porcine tracheas. Long-term effects of cryopreservation. A histological study

OBJECTIVE

The aim of this study was to optimize a decellularization protocol in the trachea of Sus scrofa domestica (pig) as well as to study the effects of long-term cryopreservation on the extracellular matrix of decellularized tracheas.

METHODS

Porcine tracheas were decellularized using Triton X-100, SDC, and SDS alone or in combination. The effect of these detergents on the extracellular matrix characteristics of decellularized porcine tracheas was evaluated at the histological, biomechanical, and biocompatibility level. Morphometric approaches were used to estimate the effect of detergents on the collagen and elastic fibers content as well as on the removal of chondrocytes from decellularized organs. Moreover, the long-term structural, ultrastructural, and biomechanical effect of cryopreservation of decellularized tracheas were also estimated.

RESULTS

Two percent SDS was the most effective detergent tested concerning cell removal and preservation of the histological and biomechanical properties of the tracheal wall. However, long-term cryopreservation had no an appreciable effect on the structure, ultrastructure, and biomechanics of decellularized tracheal rings.

CONCLUSION

The results presented here reinforce the use of SDS as a valuable decellularizing agent for porcine tracheas. Furthermore, a cryogenic preservation protocol is described, which has minimal impact on the histological and biomechanical properties of decellularized porcine tracheas.

A Standardised Approach to the Biomechanical Evaluation of Tracheal Grafts

The ideal tracheal substitute must have biomechanical properties comparable to the native trachea, but currently there is no standardised approach to evaluating these properties. Here we propose a novel method for evaluating and comparing the properties of tracheal substitutes, thus systematising both measurement and data curation. This system was tested by comparing native rabbit tracheas to frozen and decellularised specimens and determining the histological characteristics of those specimens. We performed radial compression tests on the anteroposterior tracheal axis and longitudinal axial tensile tests with the specimens anastomosed to the jaw connected to a measuring system. All calculations and results were adjusted according to tracheal size, always using variables relative to the tracheal dimensions, thus permitting comparison of different sized organs. The biomechanical properties of the decellularised specimens were only slightly reduced compared to controls and significant in regard to the maximum stress withstood in the longitudinal axis (-0.246 MPa CI [-0.248, -0.145] MPa) and the energy stored per volume unit (-0.124 mJ·mm^-3 CI [-0.195, -0.055] mJ·mm^-3). The proposed method is suitable for the systematic characterisation of the biomechanical properties of different tracheal substitutes, regardless of the size or nature of the substitute, thus allowing for direct comparisons.

Development of alginate and gelatin-based pleural and tracheal sealants

Pleural and tracheal injuries remain significant problems, and an easy to use, effective pleural or tracheal sealant would be a significant advance. The major challenges are requirements for adherence, high strength and elasticity, dynamic durability, appropriate biodegradability, and lack of cell or systemic toxicity. We designed and evaluated two sealant materials comprised respectively of alginate methacrylate and of gelatin methacryloyl, each functionalized by conjugation with dopamine HCl. Both compounds are cross-linked into easily applied as pre-formed hydrogel patches or as in situ hydrogels formed at the wound site utilizing FDA-approved photo-initiators and oxidants. Material testing demonstrates appropriate adhesiveness, tensile strength, burst pressure, and elasticity with no significant cell toxicity in vitro assessments. Air-leak was absent after sealant application to experimentally-induced injuries in ex-vivo rat lung and tracheal models and in ex vivo pig lungs. Sustained repair of experimentally-induced pleural injury was observed for up to one month in vivo rat models and for up to 2 weeks in vivo rat tracheal injury models without obvious air leak or obvious toxicities. The alginate-based sealant worked best in a pre-formed hydrogel patch whereas the gelatin-based sealant worked best in an in situ formed hydrogel at the wound site thus providing two potential approaches. These studies provide a platform for further pre-clinical and potential clinical investigations. STATEMENT OF SIGNIFICANCE: Pneumothorax and pleural effusions resulting from trauma and a range of lung diseases and critical illnesses can result in lung collapse that can be immediately life-threatening or result in chronic leaking (bronchopleural fistula) that is currently difficult to manage. This leads to significantly increased morbidity, mortality, hospital stays, health care costs, and other complications. We have developed sealants originating from alginate and gelatin biomaterials, each functionalized by methacryloylation and by dopamine conjugation to have desired mechanical characteristics for use in pleural and tracheal injuries. The sealants are easily applied, non-cytotoxic, and perform well in vitro and in vivo model systems of lung and tracheal injuries. These initial proof of concept investigations provide a platform for further studies.

How thoracic surgeon manage tracheal tumors in African country? (Case series)

Introduction

Tracheal tumors are a rare pathological entity whose diagnosis is usually delayed by clinical latency. Surgery, which consists of a tracheal resection-anastomosis with or without reconstructive reconstruction, remains the treatment that ensures the best long-term survival.

Methods

This is a retrospective study about 8 patients admitted in the department of thoracic surgery of Hassan II's university hospital of Fes for tracheal tumors management during 7 years time (December 2010 to December 2017).

Results

There were 6 men and 2 women with an average age of 44.4 years ranged from 17 to 65 years, 4 were smokers. Dyspnea was the main trigger sign. Seven (7) have undergone bronchial fibroscopy diagnostic with a finding of budding process in 5 patients, the middle of the trachea is often concerned in 3 patients, obstructing the lumen of the trachea in almost all patients. The treatment in all patients was surgical with an intubation via the operative field, 4 trachea resection-anastomosis, 4 plasty (Lateral resection with V plasty, Kergin's plasty, Mattey's tracheobronchial anastomosis and widened V-resection to the carina). The most common histological type in our series was Adenoid Cystic Carcinoma in 2 of our patients. For the other patients we have found squamous cell carcinoma (1 case), adenocarcinoma (1 case), atypical carcinoid tumor (1 case), low grade mucoepidermoid carcinoma (1 case), an adenoma pleomorph (1 case) and endotracheal goiter (1 case). The operative follow-up was simple in 7 of our patients, all of whom underwent post-operative fibroscopy within an average of 9 days. Two cases of post-operative recurrent palsy had been observed, all of which had progressed well under treatment. We have noted 2 deaths, including one at day 4 post-operative, and the other died from complications of post-radiation tracheal stenosis. Back to 32 months' average follow-up, we have enregistered a case of a distant relapse by cervical lymph node metastasis in one patient, 5 years after surgery.

Conclusion

Primary tumors of the trachea remain of reserved prognosis with 5-year survival of 57% of all histological types combined. Computed tomodensitometry and tracheobronchial fibroscopy remain the means of reference exploration in the diagnosis and assessment of surgical resectability.

The evaluation and surgical management of post-intubation tracheal strictures at a thoracic surgery referral centre in South Africa

Background

The surgical treatment of tracheal stenosis following endotracheal intubation or tracheostomy is well described in the developed world.

Objectives

To describe our surgical experience with this pathology, and highlight the nuances of its diagnosis and management in South Africa.

Methods

We reviewed the clinical records and archived imaging of all patients who underwent tracheal resection and reconstruction for post-intubation tracheal stenosis between 1 July 2003 and 31 July 2014 in the Department of Cardiothoracic Surgery at Inkosi Albert Luthuli Central Hospital, Durban, South Africa.

Results

During the study period, 42 patients underwent tracheal resection. We evaluated the preoperative bronchoscopic characteristics of the tracheal stricture in all patients, and computed tomography (CT) was used as an adjunct in 28 (66%) patients. The stricture lengths determined by CT and intraoperative measurement were strongly correlated (r (27)=0.506, p=0.006), and the stricture lengths determined by bronchoscopy and intraoperative measurement were weakly correlated (r (41)=0.201, p=0.209). A total of 36 patients (85.7%) underwent surgery via a cervical approach and 6 (14.3%) via a right thoracotomy approach. There was no early mortality, and surgery was complicated by vocal cord palsy in 4 cases, restenosis in 2 cases, infection in 1 case and paraparesis in 1 case.

Conclusion

Tracheal resection for the treatment of post-intubation tracheal stenosis can be undertaken safely with minimal complications in the developing world, with the vast majority of lesions approached via a cervical approach. A preoperative evaluation of the stricture using CT is an accurate technique for planning tracheal resection and reconstruction.

Otolaryngology in Critical Care

Diseases affecting the ear, nose, and throat are prevalent in intensive care settings and often require combined medical and surgical management. Upper airway occlusion can occur as a result of malignant tumor growth, allergic reactions, and bleeding events and may require close monitoring and interventions by intensivists, sometimes necessitating surgical management. With the increased prevalence of immunocompromised patients, aggressive infections of the head and neck likewise require prompt recognition and treatment. In addition, procedure-specific complications of major otolaryngologic procedures can be highly morbid, necessitating vigilant postoperative monitoring. For optimal outcomes, intensivists need a broad understanding of the pathophysiology and management of life-threatening otolaryngologic disease.

Prosthetic reconstruction of the trachea: A historical perspective

This review discusses the history of tracheal reconstruction; from early work to future challenges. The focus is primarily on prosthetic tracheal reconstruction in the form of intraluminal stents, patch repairs, circumferential repairs and replacement of the trachea. A historical perspective of materials used such as foreign materials, autografts, allografts, xenografts and techniques, along with their advantages and disadvantages, is provided.

Tissue Engineered Airways: A Prospects Article

An ideal tracheal scaffold must withstand luminal collapse yet be flexible, have a sufficient degree of porosity to permit vascular and cellular ingrowth, but also be airtight and must facilitate growth of functional airway epithelium to avoid infection and aid in mucocilliary clearance. Finally, the scaffold must also be biocompatible to avoid implant rejection. Over the last 40 years, efforts to design and manufacture the airway have been undertaken worldwide but success has been limited and far apart. As a result, tracheal resection with primary repair remains the Gold Standard of care for patients presenting with airway disorders and malignancies. However, the maximum resectable length of the trachea is restricted to 30% of the total length in children or 50% in adults. Attempts to provide autologous grafts for human application have also been disappointing for a host of different reasons, including lack of implant integration, insufficient donor organs, and poor mechanical strength resulting in an unmet clinical need. The two main approaches researchers have taken to address this issue have been the development of synthetic scaffolds and the use of decellularized organs. To date, a number of different decellularization techniques and a variety of materials, including polyglycolic acid (PGA) and nanocomposite polymers have been explored. The findings thus far have shown great promise, however, there remain a significant number of caveats accompanying each approach. That being said, the possibilities presented by these two approaches could be combined to produce a highly successful, clinically viable hybrid scaffold. This article aims to highlight advances in airway tissue engineering and provide an overview of areas to explore and utilize in accomplishing the aim of developing an ideal tracheal prosthesis. J. Cell. Biochem. 117: 1497-1505, 2016. © 2016 Wiley Periodicals, Inc.

Surgical treatment of air way disease

Airway lesions are treated by resecting and subsequent reconstructive surgery. Tracheoplasty and bronchoplasty are applied to inflammatory stenosis, damage due to trauma, and primary tumors of the airways. The indications for lobar (bronchial) sleeve resection are commonly applied to lung cancers that develop at the proximal portion of the lobar bronchus. Recently, extended sleeve lobectomy (ESL) is widely indicated among the routine techniques used to avoid pneumonectomy because of its reliability and effectiveness. In some cases the cancer is limited to the segmental bronchi, segmental sleeve resection is sometimes performed. In the field of respiratory surgery, carinal resection-reconstruction is one of the most rare procedures and challenging issues, involving difficult surgical techniques, anesthetic techniques, and postoperative management. Tracheal surgery was generalized so that it could be applied to any type of tracheal disease that required resection, including tumors.

A microfluidic device to apply shear stresses to polarizing ciliated airway epithelium using air flow

Organization of airway epithelium determines ciliary beat direction and coordination for proper mucociliary clearance. Fluidic shear stresses have the potential to influence ciliary organization. Here, an in vitro fluidic flow system was developed for inducing long-term airflow shear stresses on airway epithelium with a view to influencing epithelial organization. Our system consists of a fluidic device for cell culture, integrated into a humidified airflow circuit. The fluidic device has a modular design and is made from a combination of polystyrene and adhesive components incorporated into a 6-well filter membrane insert. We demonstrate the system operates within physiologically relevant shear and pressure ranges and estimate the shear stress exerted on the epithelial cell layer as a result of air flow using a computational model. For both the bronchial epithelial cell line BEAS2B and primary human tracheal airway epithelial cells, we demonstrate that cells remain viable within the device when exposed to airflow for 24 h and that normal differentiation and cilia formation occurs. Furthermore, we demonstrate the utility of our device for exploring the impact of exposing cells to airflow: our tool enables quantification of cytoskeletal organization, and is compatible with in situ bead assays to assess the orientation of cilia beating.

Clinical and biological acceptance of a fibrocollagen-coated mersylene patch for tracheal repair in growing dogs

BACKGROUND

Collagen-covered prostheses can be used as a non-circumferential segmental tracheal replacement. However, the applicability of these implants in young subjects has not yet been reported.

METHODS

In this experimental, longitudinal study, dogs aged 29-32 days underwent limited segmental tracheal replacement with a polyester prosthesis or were allocated to a control, untreated group. The dogs were evaluated clinically, endoscopically and tomographically for up to one year.

RESULTS

Although there was evidence of tracheal growth in the experimental group, tomographic measurements were significantly smaller in this group than in the control group throughout the observation period. At the end of the study, there was no evidence of implant rejection, stenosis or collapse. Normal respiratory epithelium had grown across the implanted membrane in the experimental group.

CONCLUSION

The homologous collagen mersylene membrane allowed for limited structural tracheal growth and was functionally integrated into the segmented tracheal wall in growing dogs.

Novel use of a percutaneous endoscopic gastrostomy tube fastener for securing silicone tracheal stents in patients with benign proximal airway obstruction

BACKGROUND

Benign tracheal obstruction occurs for a variety of reasons. Bronchoscopic intervention includes silicone stent placement, which effectively maintains airway patency. Stent migration is a common complication, particularly when placed in the proximal trachea. We used a novel technique of securing tracheal stents with a percutaneous endoscopic gastrostomy tube fastener (PEG-TF) to prevent stent migration. The purpose of this study was to determine the feasibility of securing silicone stents in the proximal trachea with PEG-TF.

METHODS

Silicone stents were placed under general anesthesia by rigid bronchoscopy in 7 consecutive patients with inoperable benign proximal tracheal obstruction. PEG-TFs were placed under sterile conditions with direct bronchoscopic visualization. A needle was inserted through the anterior neck and silicone stent wall allowing stylet introduction of a T-fastener into the interior of the stent. The T-fastener was secured externally by a metal clamp and cotton pledget at the surface of the neck. Patients had routine outpatient follow-up and covered the external portion of the PEG-TF with a waterproof dressing when showering.

RESULTS

All 7 PEG-TFs were placed without complications. The PEG-TFs were left in for 1 to 25 weeks. Complications of the PEG-TF included localized cellulitis and suture breakage. No stent migration occurred while the fastener was in place. Two stents were removed within 2 weeks due to patient's difficulty tolerating the stent.

CONCLUSIONS

Securing silicone stents in the proximal trachea is feasible and may prevent stent migration, but further study and possible modification of the PEG-TF device are needed.

In vitro isolation and cultivation of rabbit tracheal epithelial cells using tissue explant technique

Epithelial cells from tracheal mucosa offer significant potential as a cell source in development of tissue-engineered trachea. The purpose of this study was to investigate and optimize a suitable culture system for tracheal epithelial cells, including the methods of primary culture, passage, identification, and cryopreservation. Epithelial cells were isolated from rabbit tracheal mucosa using tissue explant technique and were subjected to immunohistochemistry, immunofluorescence, and cryopreservation after purification. Epithelial cells reached confluency at 14-15 d. Immunohistochemical staining for cytokeratin showed brown yellow-positive cytoplasm and blue-counterstained nuclei, while immunofluorescence staining for cytokeratin showed green-positive cytoplasm and clear cell outline, indicating that the cultured cells had properties of epithelial cells. After recovery, epithelial cells exhibited high survival and viability. The results demonstrated that in vitro isolation and cultivation model was successfully established to provide high proliferative capacity, typical morphology and characteristics of tracheal epithelial cells from trachea mucosa by the use of the tissue explant technique.

Myoepithelial carcinoma: first case reported in the trachea

Myoepithelial carcinoma displaying exclusively myoepithelial differentiation mainly occurs in the salivary glands and breasts, and is considered extremely rare in the trachea. We present the first documented case of a primary myoepithelial carcinoma in the trachea. The patient was a 23-year-old man who presented with shortness of breath and cough for four months. Bronchoscopy and computed tomographic (CT) scan revealed an intraluminal mass in the trachea. A standard sleeve of trachea resection with end-to-end reconstruction was performed. The tumor was mainly composed of spindle cells and epithelioid cells which exhibited relatively uniform nuclei with finely distributed chromatin and inconspicuous nucleoli, suggesting that it may arise from benign myoepithelioma. Moreover, the tumor displayed marked cytologic atypia and an infiltrative tumor border in some areas, suggesting that it was a malignant tumor. Immunohistochemically, the tumor cells were diffusely positive for AE1/AE3, Vimentin and myoepithelial makers (Calponin, P63 and GFAP). The patient's postoperative course was uneventful with no evidence of recurrence at six months after surgery.

Airway stents

Stents are used for palliation of symptoms of central airway obstruction caused by either malignant or benign conditions. Stents may be applied for maintaining airway patency after dilatation of postinflammatory and infectious strictures, for airway dehiscence after lung transplantation, and for the management of tracheobronchomalacia. Fistulas between trachea or bronchi and the esophagus and dehiscence of pneumonectomy stump can be protected with covered stents. Choice of stent depends on careful patient selection, characteristics of airway stenosis, physician's expertise, and availability of equipment. Placement of tube stents requires rigid bronchoscopy and dilatation of strictures beforehand, whereas metal stents can be applied using a flexible bronchoscope. Advantages and disadvantages of commonly used airway stents are discussed.

Wound healing modulators in a tracheoplasty canine model

Postsurgical tracheal stenosis results from fibrosis formation due to ischemia. There are healing modulators, hyaluronic acid (HA) and collagen polyvinylpyrrolidone (CPVP), which reduce collagen fibers formation. Thus we can hypothesize that the topical application of one of these modulators can diminish postsurgical tracheal scarring and stenosis. The aim of this work was to evaluate the macroscopic, microscopic, and biochemical changes of tracheal healing after the application of HA or CPVP in a canine tracheoplasty model. The study design was prospective experimental investigation in a canine model. Eighteen mongrel dogs underwent three cervical tracheal rings resection and end-to-end anastomosis. They were randomized into three groups according to treatment: group I (control group) (n = 6), topical application of saline solution on tracheal anastomosis; group II (n = 6), topical application of 15 microg HA on tracheal anastomosis; and group III (n = 6), topical application of 2.5 mg CPVP on tracheal anastomosis. They were evaluated clinical, radiological and tracheoscopically during 4 weeks. They were euthanized at the end of the study time. Macroscopic, microscopic, and biochemical changes of tracheal anastomosis healing were analyzed. Collagen formation was quantified by the Woessner method. All the animals survived the surgical procedure and study period. Macroscopic, radiologic, and endoscopic studies showed that animals in group I developed tracheal stenosis, inflammation, and firm fibrous tissue formation, and histological studies also showed severe inflammatory reaction and fibrosis formation. Groups II (HA) and III (CPVP) showed well-organized thin collagen fibers with minimal inflammatory response. Biochemical evaluation revealed a higher collagen concentration in group I animals (analysis of variance [ANOVA] p < .05 and Tukey p < .01). Thus, hyaluronic acid or collagen polyvinylpyrrolidone administered after tracheal anastomosis diminished the degree of stenosis and inflammatory reaction. Both modulators improved tracheal healing.

Development of tracheal prostheses made of porous titanium: a study on sheep

Authors report the development of a biomaterial to be used for tracheal and laryngeal reconstruction. This experimentation follows the replacement of trachea in rats with porous titanium implants. The aim of the study is to test this type of prosthesis on sheep, whose trachea is of comparable size to that of humans. Six ewes were implanted with porous titanium implants after resection of 5 cm of trachea. The planned period for the implantation was from 3 to 6 months before the sacrifice of the animals for histological analysis. After a simple immediate postoperative course, the implantations developed complications of tracheal patency, responsible for four deaths (tracheal obstruction by mucous plug n = 2, inferior necrosis of trachea n = 1, pneumopathy n = 1). The two remaining sheep presented no complications. The mechanical performance of the prostheses was good. The histological results showed an inflammatory stenosis of the tracheo-prosthetic junctions, which was not the direct result of death. The protheses were integrated by the surrounding tissue, but endoprosthetic colonisation by pseudostratified ciliated columnar epithelium was low or nil. The absence of endoprosthetic lining was responsible for the complications. The biocompatibility of the biomaterial is not in question, but the surgical procedure will have to be modified by an endoprosthetic mucous graft before implantation so as to accelerate healing process.

Primary Tracheal Malignant Neoplasms: The University of Texas MD Anderson Cancer Center Experience

BACKGROUND

Primary malignant neoplasms of the trachea are very rare and data relating to them are limited. This study was conducted to review the presentation, management, and outcomes of primary tracheal cancers at our institution, a large multidisciplinary cancer center.

STUDY DESIGN

Retrospective chart review was conducted for all patients found to have a pathologic diagnosis of primary tracheal malignancy.

RESULTS

Since 1945, 74 patients were diagnosed with primary tracheal cancers. Among these, 34 (45.9%) were squamous cell carcinomas, 19 (25.7%) were adenoid cystic carcinomas, and 21 (28.4%) were of other histologic types. Presenting symptoms were most frequently dyspnea (55.4%), hemoptysis (48.6%), cough (41.9%), and hoarseness (35.1%). Most patients (77.3%) were former or current smokers, particularly those with squamous cell carcinoma (93.3%). For the entire group of 74 patients, the 5-year disease-specific mortality rate was 72.9% and the 5-year all-cause mortality rate was 79.3%. Patients who had adenoid cystic carcinoma and those with cervical primaries had better rates of disease-specific and overall survival than others (p = 0.036 and 0.006 for the former patient group and p = 0.006 and 0.030 for the latter patient group). Among patients with incident disease treated at our institution (n = 45), those undergoing primary operation with adjuvant radiotherapy appeared to have better disease-specific and overall survival rates compared with those undergoing primary radiotherapy with or without chemotherapy (p = 0.0002 and 0.0003, respectively). Although those undergoing operation and receiving radiotherapy did better than those undergoing operation alone, the difference was not statistically significant.

CONCLUSIONS

Primary tracheal cancers are very rare, and our results should be viewed with caution, given that our population comprised a small heterogeneous group treated over a 60-year period. Although squamous cell carcinoma was the most common pathology in smokers, adenoid cystic carcinoma was more prevalent among nonsmokers. Operation with adjuvant postoperative radiotherapy is recommended for most patients.

Primary tracheal tumours

Primary tumours of the trachea can be benign or malignant and account for fewer than 0.1% of tumours. However, they are a diagnostic and therapeutic challenge. Benign tumours are usually misdiagnosed as asthma or chronic lung disease, and can delay diagnosis for months or years. Because of their rapid growth and onset of haemoptysis, malignant tumours are often diagnosed earlier than benign tumours and patients thus often present with locally advanced disease. Inappropriate treatment is an equally frustrating issue. Modern techniques for tracheal surgery-laryngotracheal, tracheal, or carinal resection-combined with radiotherapy, can be offered curatively with low perioperative risks. Nevertheless, the low numbers of patients undergoing resection and the associated poor survival in epidemiological studies over the past two decades have shown that surgery is rarely considered outside referral centres, with radiotherapy or another form of local treatment (eg, endotracheal stents, debridement, brachytherapy) generally preferred. The liberal use of these other techniques should be avoided because surgery has the potential to cure all patients with benign and low-grade tumours and most patients with malignant primary tracheal tumours, and other techniques are usually palliative at best.

Bioartificial tracheal grafts: can tissue engineering keep its promise?

A huge variety of graft materials and transplantation approaches have been applied for decades in order to generate a clinically applicable tracheal substitute; so far, without success. Today, tissue engineering, the creation of man-made functional biological organs or tissue replacements from biodegradable carrier structures and autologous cells, may represent an alternative to the shortage of suitable grafts for reconstructive airway surgery. Partial success has been obtained by numerous groups following different concepts and strategies. In this article, tissue engineering approaches towards the bioartificial airway prosthesis are discussed, focusing primarily on recent developments in the field.

Repair of postintubation tracheoesophageal fistula in polytrauma patients

OBJECTIVE

We present our modest experience in treating tracheoesophageal fistula (TEF) in polytrauma patients where tracheal resection turns to be risky due to the size of the fistula and to the general condition of the patient.

MATERIALS AND METHODS

Four polytrauma patients, three male and one female were treated at our department due to postintubation TEF. Confirmation was obtained endoscopically and radiologically. Surgical treatment consisted of identification and dissection of the fistulous tract and closure of the tracheal defect by transposing strap muscles and suturing them to the defect. Finally, the oesophageal defect was closed and a flap of sternocleidomastoid muscle was interposed between oesophagus and trachea.

RESULTS

There was no intraoperative mortality. Three of our patients had an excellent result. The one who unfortunately returned to mechanical ventilation due to respiratory insufficiency developed a recurrent fistula.

CONCLUSIONS

(1) Repair of postintubation TEF should be delayed until the patient is fully stabilised and weaned from ventilation. (2) Indirect closure of the tracheal defect with strap muscle transposition and sternocleidomastoid muscle interposition between oesophagus and trachea can be lifesaving.

Central Airway Obstruction

Central airway obstruction is a problem facing all medical and surgical subspecialists caring for patients with chest diseases. The incidence of this disorder appears to be rising because of the epidemic of lung cancer; however, benign causes of central airway obstruction are being seen more frequently as well. The morbidity is significant and if left untreated, death from suffocation is a frequent outcome. Management of these patients is difficult, but therapeutic and diagnostic tools are now available that are beneficial to most patients and almost all airway obstruction can be relieved expeditiously. This review examines current approaches in the workup and treatment of patients suffering from airway impairment. Although large, randomized, comparative studies are not available, data show significant improvement in patient outcomes and quality of life with treatment of central airway obstruction. Clearly, more studies assessing the relative utility of specific airway interventions and their impact on morbidity and mortality are needed. Currently, the most comprehensive approach can be offered at centers with expertise in the management of complex airway disorders and availability of all endoscopic and surgical options.

The history of tracheal surgery

Tracheal surgery, which did not exist in a coherent, systematic fashion 45 years ago, has developed techniques that allow resection of approximately half of the adult trachea with primary reconstruction, largely by anatomic mobilization procedures. Dependable methods have also been developed for laryngotracheal and carinal resection and reconstruction. The daunting problem of long congenital tracheal stenosis appears to be largely solved by slide tracheoplasty. In the past four decades much has also been learned about the etiology, natural history, pathology, and (in some cases) prevention of tracheal diseases including primary and secondary tumors, postintubation injuries, and idiopathic stenosis.