First-line tracheal resection and primary anastomosis for postintubation tracheal stenosis

Tracheal Resection for Post-intubation/Post-tracheostomy Tracheal Stenosis

Post-intubation and post-tracheostomy tracheal stenoses are relatively uncommon common complications of prolonged intubation. Patients with tracheal stenosis usually present with stridor and dyspnea once a significant portion of their airway is compromised. Tracheal resection and reconstruction offer durable treatment options for these patients with minimal risk once initial endoscopic treatment has failed.

The safety and effectiveness of the treatment of refractory post-intubation subglottic stenosis using short bronchial Dumon stent: a pilot study

Background

Post-intubation subglottic stenosis (PI-SGS) is a fatal disease which could result in partial or complete narrowing of the airway. Although airway stenting is commonly used as an alternative treatment for PI-SGS patients unsuitable for surgery, complications including stent migration and excessive granulation tissue formation are frequently encountered. Additionally, tracheotomy is necessary in patients undergoing T-tube placement. Therefore, it is necessary to further enhance the effectiveness of airway stenting in refractory PI-SGS. In this study, we aimed to evaluate the safety and effectiveness of utilizing short bronchial Dumon (BD) stents in managing refractory PI-SGS.

Methods

PI-SGS patients who were not suitable for surgery and in whom previous interventional treatments had proven ineffective were enrolled. Short BD stents were inserted via rigid bronchoscopy under general anesthesia. Complications and outcomes were assessed by follow-ups.

Results

Fourteen patients were included and successful stent insertion was achieved in all cases. The median diameter and length of stents was 12 (0.25) and 33.5 (5) mm, respectively. During the 6-month follow-up period, complications were reported in five patients. Granulation tissue formation was the most frequently observed complication (4 in 14 patients, 28.57%), followed by stent migration (2 in 14 patients, 14.29%). Out of the total participants, 11 patients (78.57%) demonstrated good tolerance to the stent, while 3 (21.43%) required stent removal. Among these three patients, two finally underwent subsequent T-tube insertion after the removal. Twelve patients (85.71%) avoided the tracheotomy and T-tube insertion.

Conclusions

The utilization of short BD stents appears to be a safe and effective approach for managing refractory PI-SGS. The complications and tolerability are acceptable.

Bronchoscopic holmium laser ablation continuous cryoablation for the treatment of airway stenosis caused by tissue hyperplasia after tracheal intubation: clinical case observation

This study aimed to design a standardised bronchoscopic holmium laser ablation continuous cryoablation for the treatment of airway stenosis caused by tissue hyperplasia after tracheal intubation and to retrospectively analyse its safety and feasibility. We collected the data of patients who had undergone bronchoscopic holmium laser ablation continuous cryoablation due to airway stenosis caused by tracheal mucosal tissue hyperplasia after tracheal intubation. The patients' baseline characteristics, ablation effects, surgical complications and other data were analysed. In total, 16 patients were enrolled in this study. On average, airway stenosis occurred 96.00 (interquartile range, 69.75-152.50) days after tracheal intubation and bronchoscopic holmium laser ablation continuous cryoablation took an average of 90.38 minutes (standard deviation: 16.78). After the first continuous cryoablation, 75.0% (12/16) of the patients had complete ablation of hyperplastic tissue, and 25.0% (4/16) had most of the hyperplastic tissue (>50%) removed. Altogether, 18.75% (3/16) and 6.25% (1/16) of the patients had complete ablation of hyperplastic tissue after the second and third cryoablation, respectively. Moreover, one patient (6.25%) had minimal wound bleeding postoperatively, and no other surgical complications occurred. No airway stenosis was found in all enrolled patients during follow-up 1 and 6 months after the last cryoablation. According to the above results of our small sample study indicated that bronchoscopic holmium laser ablation continuous cryoablation seems safe and effective for treating airway stenosis caused by tissue hyperplasia after tracheal intubation.

Voice Restoration after Traumatic Subglottic Tracheal Stenosis

Tracheal stenosis post intubation is one of the most common complication for which resection and anastomosis is done. Here we present a 21 year male patient who was intubated post organophosphorous poisoning. Diagnosed with tracheal stenosis post intubation and managed with tracheal resection and anastomosis with uneventful recovery. Post intubation tracheal stenosis is one of the serious complications and requires a multidisciplinary team and high volume centre for adequate management. Considering the fact that this case report has tracheal stenosis of grade IV type with resected length of tracheal cartilage of more than 3 cm and trachea- tracheal anastomosis makes this a rare case report.

Predictors of response to endoscopic management of subglottic/tracheal stenosis in patients without tracheostomy

INTRODUCTION

Subglottic and tracheal stenosis (SGTS) in adults is an acquired or idiopathic condition that can lead to dyspnea, and even life-threatening airway obstruction. Endoscopic techniques have advanced and largely eclipsed open surgery, with open surgery now reserved for refractory cases (Hseu et al., 2013; Feinstein et al., 2017). Currently, there is no accepted guideline for the endoscopic treatment of SGTS. Thus, the aim of the present study is to examine the impact of various clinical and pathological characteristics on outcomes to endoscopic treatment in a cohort of SGTS patients.

DISCLOSURE

None of the authors have any financial or personal relationship that could cause a conflict of interest regarding this article.

METHODS

Retrospective chart review was performed for 41 patients presenting with SGS without a tracheostomy over a 4-year-period (2018-2022), within a single tertiary care center. Quantitative outcomes including number of dilation procedures undergone and need for open procedures were examined. The qualitative variables included a history of pulmonary disease, prior tracheostomy/tracheal resection, presence of tracheomalacia, granulation tissue, excessive dynamic airway collapse (EDAC), and etiology of idiopathic subglottic stenosis.

RESULTS

The presence of granulation tissue seen on tracheoscopy was associated with a higher number (4+) of dilation procedures (p = 0.01). A history of pulmonary disease (p = 0.037), the presence of tracheomalacia (p = 0.039), and the presence of granulation tissue (0.003) were all associated with a need for open procedures.

CONCLUSION

Patients with the presence of granulation tissue, tracheomalacia, and a history of pulmonary disease were more associated with more severe disease requiring either a higher number of endoscopic procedures or need for open procedures.

Site of Tracheostomy and Its Influence on The Surgical Outcome and Quality of Life After Tracheal Resection and Anastomosis in Patients with Tracheal Stenosis

Introduction  With the advances in critical care, the incidence of post intubation tracheal stenosis is increasing. Tracheal resection and anastomosis have been the gold standard for the management of grades III and IV stenosis. Scientific evidence from the literature on the determining factors and outcomes of surgery is not well described. Objective  This study was aimed at determining the influence of tracheostoma site on the surgical outcomes and postoperative quality of life of patients undergoing tracheal resection anastomosis. Methods  Thirteen patients who underwent tracheal resection and anastomosis during a period of 3 years were followed up prospectively for 3 months to determine the degree of improvement in their quality of life postsurgery by comparing the pre and postoperative validated Tamil/vernacular version of RAND SF-36 scores and Medical Research Council (MRC) dyspnea score. Results  As per preoperative computed tomography (CT), the mean length of stenosis was found to be 1.5 cm while the mean length of trachea resected was 4.75 cm. We achieved a decannulation rate of 61.53%. There was an estimated loss of 3.20 +/- 1.90 cm of normal trachea from the lower border of the stenosis until the lower border of the stoma that was lost during resection. Analysis of SF-36 and MRC dyspnea scores revealed significant improvement in the domains of physical function postoperatively in comparison with the preoperative scores ( p  < 0.05). Conclusion  Diligent placement of tracheostomy in an emergency setting with respect to the stenotic segment plays a pivotal role in minimizing the length of the resected segment of normal trachea.

[Non-standard long-term tracheal stenting with silicone endoprosthesis for cicatricial stenosis]

Endoscopic approach with recanalization and stenting is one of the methods for cicatricial tracheal stenosis. Major complications may occur if service life of stents is not observed. However, there are currently no clear timing for stenting. In world practice, there are no indications on lifelong stenting for cicatricial tracheal stenosis. Restenosis is more common after stent removal and requires repeated stenting or another treatment. In case of prolonged stenting, silicone stent should be periodically replaced with a similar one due to destruction of silicone rubber. As a rule, this maneuver is necessary after 1-3 years. Currently, there is no information about maximum allowable duration of stent without replacement and possible complications. Condition of trachea after prolonged stenting is also unknown. We present long-term (27 years) tracheal stenting with a silicone stent. Stent fragmentation and dislocation throughout this period led to respiratory failure and emergency removal. Tracheal lumen was satisfactory immediately after procedure. However, restenosis appeared after 1.5 months and required endoscopic dilation with discussion of appropriate treatment option. However, the patient refused tracheal resection with anastomosis and underwent repeated stenting with similar stent and favorable immediate result.

A case of pyothorax after treatment of burn inhalation injury. A case report

INTRODUCTION

Inhalation injury is a major complication of fire accidents. Delayed onset of tracheal stenosis is one of the chronic complications of inhalation injury. Here, we report a case of acute empyema as a complication of inhalation injury.

PRESENTATION OF CASE

A 38-year-old-man who underwent a tracheostomy following an inhalation injury when he was 25-years of age was admitted with a diagnosis of right-side pyothorax. We attributed the pyothorax to insufficient bronchial toilet secondary to preoperative tracheal stenosis and tracheal mucosal damage as a complication of inhalation injury, as confirmed using laryngofiberscopy. Conservative therapy was insufficient, therefore, surgical drainage was performed. At the time of surgery, following general anesthesia induction, the insertion of a single-lumen tube was difficult owing to severe tracheal stenosis. As a result, we performed an emergency tracheostomy followed by empyema curettage.

DISCUSSION/CONCLUSION

Tracheal stenosis due to tracheal basal membrane injury and mucosal membrane injury resulted in sputum clearance disorder. These changes led to pyothorax. Preoperative airway safety should be carefully planned when operating on patients with tracheal stenosis.

Two cases with postintubation tracheal stenosis after COVID-19 pneumonia

Only a small percent of all intubated SARS-CoV-2-positive patients survive because of the development of severe respiratory and multiorgan failure. The development of tracheal stenosis after orotracheal intubation or tracheostomy is a dangerous complication with gross consequences for the patient and medical staff. Endoscopic interventional procedures could be used in simple tracheal stenosis and surgical resection and anastomosis are reserved for complex stenosis or after unsuccessful endoscopic treatment. We present two cases with tracheal stenosis as a complication of prolonged intubation in COVID-19 survivors which was diagnosed up to 6 months after discharge. Clinical management and surgical techniques are also discussed.

Airway Surgery for Laryngotracheal Stenosis During the COVID-19 Pandemic: Institutional Guidelines

Objective

The management of laryngotracheal stenosis is challenging, as patients usually require in-time interventions. The current coronavirus disease 2019 (COVID-19) pandemic has added unique challenges to this procedure. The presence of the virus in high concentrations in the aerodigestive tract and the need for an open airway during surgery can increase the risk of aerosolization of the virus and subsequent infection of the surgical, anesthetic, and operating room (OR) personnel.

Design

Retrospective cohort study.

Setting

University hospital.

Participants

Patients who underwent airway interventions between March and October 2020.

Interventions

A protocolized strategy was initiated during the COVID-19 pandemic to facilitate the consistent management of all patients undergoing airway interventions.

Measurements and Main Results

During a seven-month period, 34 patients were managed with this policy. All threatened airways were managed successfully and no healthcare workers dealing with such procedures were infected. Priorities during the current novel coronavirus pandemic are ensuring the safety of healthcare professionals and offering urgent bronchoscopic and surgical airway interventions for patients with progressive symptoms and threatened airways.

Conclusions

Surgical and bronchoscopic management of laryngotracheal stenosis presents a unique challenge during the COVID-19 pandemic, requiring careful consideration of patient triage and the development of protocols that minimize risk to patients and healthcare professionals. Close collaboration between thoracic surgeons and anesthesiology teams is essential to safely navigate and handle these threatened airways while mitigating the risk of viral aerosolization.

Otoendoscope combined with ablation electrodes for treatment of benign tracheal stenosis caused by granulation tissue hyperplasia after tracheotomy

Benign tracheal stenosis mainly appears due to tracheotomy, tuberculosis, trauma, benign tumor, or ventilation. With the increase in the number of tracheotomies and the prolongation of the life span of patients after incision, the long-term complications after tracheotomy gradually increase, among which intratracheal granulation hyperplasia is a more serious complication. The present case describes a 59-year-old male with granulation tissue hyperplasia induced by tracheotomy. He underwent tracheal resection to remove the granulation tissue and he remained well after the follow-up. Even though the endoscopic intervention and tracheal resection are readily accessible, they usually quite challenging. Here we summarize the present details on this condition.

Tracheotomy-coblation for acquired subglottic tracheal stenosis: a case report

BACKGROUND

Tracheal stenosis caused by tracheotomy and intubation is considered intractable. Although the segmental tracheal resection and endoscopic intervention are available, they usually result in great operation injury or are difficult to perform.

CASE PRESENTATION

A patient with acquired tracheal stenosis was treated with tracheotomy-coblation. The patient was followed up by bronchoscopy every 2 months. After 6-month follow-up, the symptoms of dyspnea and hoarseness disappeared and no tracheal stenosis was observed.

CONCLUSIONS

The present technique, tracheotomy-coblation, is advantageous with less injury and easy to perform.

Single-stage tracheal and cricotracheal segmental resection with end-to-end anastomosis: Outcome, complications, and risk factors

OBJECTIVE

Management of tracheal stenosis remains controversial. Endoscopic interventions commonly provide immediate relief of symptoms, but are associated with high recurrence rates. In contrast, high success rates have been reported in patients undergoing tracheal resection. However, well-defined indications and contraindications for tracheal resection are lacking and previous studies commonly ignore patient-related outcomes (e.g. dyspnoea). We aimed to evaluate the outcome of tracheal resection at our institution and identify risk factors for complications.

METHODS

All adult patients undergoing tracheal resection at Aarhus University Hospital between January 2009 and September 2016 were included RESULTS: Twenty-seven patients were included. The most frequent aetiologies for tracheal stenosis were previous tracheostomy (n=8), prolonged intubation (n=3), a combination of the two (n=5), and intraluminal tumour (n=7). Sixteen patients underwent high tracheal resection, seven patients low tracheal resection, and four patients partial cricotracheal resection. Surgical success (no dyspnoea and no need for additional intervention) was achieved in 74% of patients. Four of six patients undergoing resection because of malignant disease were recurrence-free during the follow-up period. Fifteen (56%) patients suffered complications (transient or permanent). Four (15%) patients had recurrent stenosis and underwent reintervention. Other permanent complications included idiopathic hoarseness (15%), unilateral recurrent nerve palsy (11%), and dysphagia (7%). Previous treatment (endoscopic and open surgery) (OR=5.5, p=0.06) and chronic diseases (OR=8.3, p=0.02) were associated with increased risk for complications.

CONCLUSIONS

Tracheal resection was efficient treatment for the alleviation of dyspnoea in adults with tracheal stenosis. However, complications were frequent and careful preoperative patient selection and information are crucial.

Surgical treatment of postintubation tracheal stenosis: A retrospective 22-patient series from a single center

BACKGROUND/OBJECTIVE

We aimed to present cases of postintubation tracheal stenosis (PITS), all due to long-term intubation and treated surgically in a university hospital, and to discuss them in light of the literature.

METHODS

In this retrospective study, 22 patients who were treated with tracheal resection and reconstruction due to PITS were included. Demographics, intubation characteristics, localization of stenosis, surgical technique and material, postoperative complications, and survival of patients were recorded.

RESULTS

The mean intubation duration was 16.95 days with a median of 15.00 days. Collar incision was applied in 19 cases (86.4%); in two cases (9.1%) a median sternotomy incision was used; and in the remaining case (4.5%), a right thoracotomy incision was made. The mean tracheal stenosis length was 2.14 cm (mean excision length, 2.5 cm). In 17 cases (77.3%), the anterior walls were supported with vicryl (polyglactin) suture one by one. No postoperative complications were observed in 12 cases (54.5%). No recurrence developed during the long-term follow-up of 15 of the 22 patients (68.2%). Two patients (9.1%) died in the early stages after surgery, and five patients (22.7%) had a stent inserted due to restenosis.

CONCLUSION

Tracheal resection and end-to-end anastomosis are the most efficient techniques in cases without medical contraindications, despite emerging stent or endoscopic procedures. Endoscopic interventions can be suggested as an alternative to surgery in patients for whom surgery cannot be performed or who develop recurrence.

Benign tracheal stenosis a case report and up to date management

Benign tracheal stenosis is situation that occurs usually after stress is applied to a certain area in the trachea during the intubation of a patient or inflammation caused during an infection. In the current case report we will present a 65-year-old man with a benign tracheal stenosis due to a 15-day intubation with a high pressure and low volume intubation tube. Current methodology was applied in his case with an excellent result with a 1-year follow up. Cryotherapy, electrocautery-knife, balloon dilation and semi-rigid bronchoscopic technique were applied. Currently there are several techniques that can be used by pulmonary physicians or ear, nose and throat experts. It remains for the treating physician to choose its method based on his training, equipment and tissue damage.