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J Thorac Cardiovasc Surg 1995;109:486-493
© 1995 Mosby, Inc.
GENERAL THORACIC SURGERY |
Boston, Mass.
From the General Thoracic Surgical Unit, Massachusetts General Hospital, and the Department of Surgery, Harvard Medical School, Boston, Mass.
Address for reprints: H. C. Grillo, M.D., Massachusetts General Hospital, Boston, MA 02114.
Abstract
A total of 503 patients underwent 521 tracheal resections and reconstructions for postintubation stenosis from 1965 through 1992. Fifty-three had had prior attempts at surgical resection, 51 others had undergone various forms of tracheal or laryngeal repair, and 45 had had laser treatment. There were 251 cuff lesions, 178 stomal lesions, 38 at both levels, and 36 of indeterminate origin. Sixty-two patients with major laryngeal injuries required complete resection of anterior cricoid cartilage and anastomosis of trachea to thyroid cartilage, and 117 had tracheal anastomosis to the cricoid. A cervical approach was used in 350, cervicomediastinal in 145, and transthoracic in 8. Length of resection was 1.0 to 7.5 cm. Forty-nine had laryngeal release to reduce anastomotic tension. A total of 471 patients (93.7%) had good (87.5%) or satisfactory (6.2%) results. Eighteen of 37 whose operation failed underwent a second reconstruction. Eighteen required postoperative tracheostomy or T-tube insertion for extensive or multilevel disease. Twelve died (2.4%). The most common complication, suture line granulations (9.7%), has almost vanished with the use of absorbable sutures. Wound infection occurred in 15 (3%) and glottic dysfunction in 11 (2.2%). Five had postoperative innominate artery hemorrhage. Resection and reconstruction offer optimal treatment for postintubation tracheal stenosis. (J THORACCARDIOVASC SURG 1995;109:486-93)
Postintubation tracheal injuries remain the most common indication for tracheal resection and reconstruction, despite identification of the causes of these lesions and development of techniques for their avoidance. Our series of 503 patients treated from 1965 through 1992 spans a period in which the lesions were recognized and characterized, their origin clarified, and techniques for definitive surgical treatment developed and applied. This cumulative series includes patients from prior reports in 1969 and 1979. 
1,2
PATIENTS AND METHODS
Patients.
A total of 503 patients underwent tracheal resection and reconstruction for postintubation lesions. They included 266 male and 237 female patients with an age range of 6 to 85 years (average 44 years) (Table I). The balloon cuff of an endotracheal or tracheostomy tube accounted for 251 lesions. One hundred seventy-eight lesions were at the site of a tracheostomy, and 38 patients had evidence of both lesions. In 36 patients, the exact site was uncertain, often because of prior attempts at treatment including multiple tracheostomies. Of the 503 patients, 441 had lesions that were principally tracheal, and 62 had involvement of the subglottic larynx.
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Many patients had undergone prior attempts at surgical treatment before referral. These included resection (n = 53), tracheal operations such as wedge resection, splinting, or fissure (n = 31), and laryngeal procedures such as stenting, grafting, or fissure (n = 20). Sixty had had T-tubes placed and at least 45 had had laser treatment. Eight patients had prior repairs of tracheoesophageal fistula (TEF), three of which had failed.
Diagnosis and selection of patients for operative repair have been outlined in the past 2
Operative treatment.
A total of 521 tracheal resections and reconstructions were done on 503 patients. Thirteen patients had restenosis after an initial procedure and were reoperated on at a later date. Five patients had immediate failure because of residual tracheal malacia and were reoperated on within hours of their initial procedure. These cases are considered as complications and not counted as additional reconstructions.
The anesthetic techniques have been described 3 A rigid bronchoscope is used at the time of resection. If the residual airway is 5 mm in diameter or less, dilation is done serially with dilators and pediatric bronchoscopes with the patient under general anesthesia. If the lumen is greater than 6 mm intubation is carried out above the lesion, if feasible. Existing stomas are often used for intubation, especially in cases of subglottic laryngeal stenosis. In this series, the initial procedure was done through a cervical incision in 350 patients. In 145 patients a partial upper sternal division through the sternal angle was used, with two more patients requiring the addition of right anterior thoracotomy to this approach. Six patients underwent repair via a high posterolateral thoracotomy. Few if any operations would now be done through a thoracotomy. We have learned that even supracarinal benign stenosis is almost always reparable via partial upper sternotomy posterior to the great vessels.
Surgical techniques have been detailed previously. 4 The amount of trachea resected ranged from 1.0 to 7.5 cm (Table II) and was most commonly between 2 and 4 cm. A tension-free anastomosis was usually obtained by means of cervical flexion after only the anterior surface of the trachea had been freed from the cricoid cartilage to the carina. This technique preserves the lateral blood supply, which is critical. The amount of trachea that can be resected and permit safe approximation varies with age and build of the patient, the pathologic condition, and prior surgical procedures. Cervical flexion is maintained with a suture from the submental crease of the chin to the presternal skin for 7 days after the operation. Laryngeal release was useful when approximation could not be easily obtained. In nine patients thyrohyoid release, described by Dedo and Fishman, 5 was used. This technique was replaced with the suprahyoid release described by Montgomery 6 in the remaining 40 patients. One patient required intrapericardial hilar release.
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7,8
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The suture material used for anastomosis changed over time Before 1978, 4-0 Dacron polyester or Tevdek polyester (Deknatel, Inc., Fall River, Mass.) was used, as well as Mersilene polyester and Prolene polypropylene (Ethicon, Inc., Somerville, N.J.). Because of the prevalence of granulomas at the suture line, an absorbable suture, 4-0 Vicryl polyglactin 910 (Ethicon), has been used since 1978. Monofilament PDS polydioxanone (Ethicon) was tried and discarded.
The management of TEF resulting from intubation has been reported. 9,10 Twenty-five patients in this series with TEF required tracheal resection and reconstruction. Seven patients who had stenosis accompanied by extensive tracheomalacia required one or more polypropylene rings placed around the trachea for support. Anastomoses were covered with adjacent tissues in 84: thyroid isthmus in 50, cervical strap muscle in 26, and other tissue in 8—including thymus and pericardial fat pad. Tissue was interposed, in general, between the trachea and innominate artery if the anastomosis was adjacent or if the artery had been previously dissected.
RESULTS
Follow-up was obtained by office visit, or patients were contacted by mail and telephone. The results have been classified as good, satisfactory, failure, and death. The result is described as good if the patient is functionally able to perform usual activities and if postoperative roentgenograms or bronchoscopic examinations show an anatomically good airway. Results are considered satisfactory if the patients can perform normal activities but are stressed on exercise, if they have abnormalities such as a paralyzed or partially paralyzed vocal cord, and if significant narrowing is evident on either endoscopic or roentgenologic examination, even if the patient's level of activity does not clinically evidence this.
The average length of follow-up was 3 years The results were good in 440 patients and satisfactory in 31 patients; there were 20 failures and 12 deaths (Table III). Patients in whom the operation failed were treated with tracheostomy (n = 11), T-tube (n = 7), or dilations (n = 2). The possible effect of various factors—historical, pathologic, and technical—on outcome are considered in the following sections.
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Table IV. In 75.5% of the 53 patients who had previous resection and reconstruction, the outcome was good; in comparison, 86% of those without prior resection and reconstruction had a good outcome. The failure rate of this group was 5.6% with a 3.8% mortality, comparing unfavorably with 3.6% and 2.1% rates, respectively, in the group without prior resection. Despite a surprisingly high proportion of good results (87%), reconstruction after tracheal operations other than procedures itemized in Table IV led to the highest failure rate (9.7%). The extensive and complex nature of these prior procedures probably explains this. The procedures included insertion of a Marlex tube (Bard Implants, Billerica, Mass.), cartilage grafts, hyoid bone grafts, staged cutaneous trough procedures, and cutaneous grafts with stents. Previous T-tube, laser therapy, or TEF repair did not seem to affect outcome adversely.
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Table V). The failure rate progressively increased with a higher level of anastomosis. The failure rates were 2.2% for a trachea-trachea anastomosis, 6.0% for a trachea-cricoid anastomosis, and 8.1% for a trachea-thyroid anastomosis. Minor complications also became more prevalent with each level, from 16% to 17.1% to 21%, respectively. The major complication rate did not seem to change (13.9%, 15.4%, 12.9%, respectively).
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TEF.
Twenty patients underwent repair of a TEF concomitantly with tracheal resection and reconstruction for stenosis. This group included three patients who had prior TEF repair that failed. The outcome is listed in 
Table V. Of the 20 patients, 18 had a good outcome, one required reoperation with a satisfactory outcome, and one patient died.
Tracheomalacia.
Because of extensive malacia in an area of trachea that could not be resected, seven patients had polypropylene rings placed around the segment of malacia in addition to a resection and reconstruction of adjacent tracheal stenosis. Of the seven patients, three had a good outcome, there was one failure that required a permanent T-tube, and one death. Two patients required reoperation, with one good result and one satisfactory result (see Table V). Shorter segments of pure malacia or in association with stenosis were treated by resection.
Postoperative reintubation.
The need for reintubation after reconstruction indicated a problem. It is not surprising, therefore, that results in 23 patients who were reintubated are poor. Intubation was done most often on the operative day (n = 9) and in the first week (n = 11), with one reintubation at 30 days. Proximity of repair to the glottis increased the likelihood: 9 intubations in 324 anastomoses of trachea to trachea, 8 in 117 to cricoid, and 6 in 62 to thyroid cartilage. Of these patients, 6 obtained a good result, 5 satisfactory, 1 poor, 4 needed tracheostomy or T-tube insertion, and 5 died.
Concurrent tracheostomy.
In 27 a tracheostomy was deemed advisable at the conclusion of reconstruction, for such indications as an edematous larynx, vocal cord paralysis, or uncorrectable narrowing immediately beneath the glottis. Some tracheostomies were done routinely early in our experience with laryngotracheal reconstruction, a routine now abandoned. 8 Four T-tubes were also placed in the operating room, for example, to control a high second stenosis after resection of the lower stenosis. Final results were good in 21, satisfactory in three, and two needed a tracheostomy permanently. One was reoperated on. When tracheostomy must be done, the stoma is carefully located at least 1 cm distal to the anastomosis (where there is a high anastomosis). The anastomosis is covered with thyroid isthmus or strap muscle. If the innominate artery is close, as it often is, a strap muscle is sutured to the trachea over the artery to partition the tracheostomy from it. In patients in whom a tracheostomy is thought likely to be needed later, the same compartmentalization is performed and the site of a potential stoma is marked with a fine silk suture.
Complications.
Complications are summarized in Table VI.
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Dehiscence and restenosis.
Anastomotic dehiscence or restenosis occurred in 29 patients. Seven patients with this complication died; two also had innominate artery erosion. Eight patients were managed with repeated resection and reconstruction, all with either good (n = 6) or satisfactory (n = 2) results. Four patients required permanent tracheostomy. Five required a T-tube, three of which were temporary. Three patients had dehiscence of a small portion of the anastomosis. Two of these required reexploration and primary closure and one patient with a minimal leak was successfully managed with drainage of the cervical wound and antibiotics. Two patients required repeated dilations.
Laryngeal dysfunction.
A total of 25 patients had varying degrees of laryngeal dysfunction after the operation. Fourteen had minor or temporary dysfunction that necessitated no specific treatment. Eleven had more severe dysfunction. Of these, seven required tracheostomy; four of these were temporary. One patient required a permanent T-tube, and another a subglottic stent. Two patients required gastrostomy tube feedings for persistent aspiration resulting from glottic dysfunction. One death occurred in this group.
Laryngeal complications—aspiration or vocal cord dysfunction--appeared in four of nine patients undergoing thyrohyoid laryngeal release (44%) and in eight of 40 (20%) undergoing suprahyoid release. Laryngotracheal resection (trachea-thyroid cartilage anastomosis) plus laryngeal release in eight patients led to three minor and four major complications in six of the eight patients. These complications included dysphagia in three, with aspiration, also, in one, malacia in one, and dehiscence in whole or in part in three. Three of the four patients with major complications ultimately had good results.
Tracheal malacia.
Residual tracheal malacia was identified either during or after the operation in 10 patients. There were two deaths in this group. Five patients required reoperation; four of these underwent second resection and reconstruction and one patient underwent plastic ring splinting of the malacic segment. Results of reoperation were good in two patients and satisfactory in two; the fifth required permanent tracheostomy. Two patients were treated with a T-tube, one of which was temporary. One patient required temporary tracheostomy.
Hemorrhage.
Five patients bled from the innominate artery. Three of them died, two of whom had concomitant anastomotic separation. One patient was managed successfully with repair of the artery, and one was managed by division of the innominate artery.
Anastomotic edema.
Four patients had swelling at their anastomosis. In one patient the swelling was minor and was treated with oral steroids. Two patients were treated with temporary tracheostomy and one with a temporary T-tube.
Infection.
Infectious complications developed in 34 patients. Wound infections accounted for 15 of these. Eight minor infections were treated only with intravenous antibiotics and seven more extensive sternal infections required operative debridement.
Nineteen patients had bronchitis or pneumonia. Fourteen of these required bedside bronchoscopic treatment and antibiotics. Five more severe cases resulted in one death. Three patients were managed with temporary tracheostomy and two with reintubation.
Other.
One postoperative myocardial infarction occurred and resulted in the patient's death. Three patients with postoperative pneumothorax were treated with a chest tube. One of each of the following complications was seen: intravenous line infection, deep venous thrombosis, atrial fibrillation, insulin reaction, and aspiration through a T-tube necessitating conversion to tracheostomy.
Deaths.
Twelve perioperative deaths occurred. Complications related to anastomotic dehiscence were the most common causes, accounting for seven deaths. Two patients were supported with ventilators at the time of resection, and three required postoperative reintubation for retained secretions. One patient required early reintubation and reoperation to stabilize a flail chest. One patient had received mediastinal irradiation for Hodgkin's disease, with resultant massive peritracheal fibrosis and failure of healing despite omental wrapping. Two patients had a trachea-innominate artery fistula after dehiscence. One patient had isolated trachea-innominate artery hemorrhage, probably because of intraoperative trauma. Two patients died of airway obstruction as a result of residual tracheal malacia. There was one postoperative fatal myocardial infarction. One patient died at home of respiratory failure of unknown cause.
DISCUSSION
The causes of postintubation stenosis have been well established. 11,12 Prevention is possible to a high degree by use of large volume, low pressure cuffs 13 and careful management of stomal tubes. However, the lesions continue to appear, most likely because of overinflation of nonelastic plastic cuffs and leverage on tracheostomy tubes. Indeed, an additional 24 patients have been operated on since this study was closed.
A host of "conservative" treatments, including repeated dilation, local and systemic steroids, cryosurgery, fulguration, laser treatment, and prolonged or permanent stenting with T-tubes and other stents, have largely proved successful and without excessive complications only for highly selected lesions. 14-16 Failure rates with lasertreatment range from 23% to 43%. 17 Segmental tracheal resection 1,2,18-20 remains the preferred definitive treatment for postintubation stenosis. In our series good or satisfactory results were obtained in 93.7% of all resections, with failure in 3.9% and a mortality of 2.4%. Our good or satisfactory results in 90.3% of patients after the more complex single-stage resection and reconstruction of subglottic larynx and trachea 7,8,21,22 for stenosis at this difficult level confirm the appropriateness of this approach. Failure occurred in 8.1% of these patients and death in 1.6%. The increased failure rate counsels a continued cautious approach to laryngotracheal reconstruction.
Basic principles of tracheal reconstruction introduced in the 1960s and 1970s served to reduce the prevalence of many complications. These principles include avoidance of excessive anastomotic tension, maintenance of tracheal blood supply, and meticulous dissection and anastomosis. Adoption of absorbable sutures for anastomosis (4-0 Vicryl) has almost eliminated anastomotic granulations and some late restenosis. In clinical use, monofilament absorbable sutures (PDS) have shown no advantages and are more cumbersome to use. Laryngeal release was not often necessary, except in patients who had undergone a prior failed reconstruction. As might be expected, such release, combined with a lengthy resection (the indication for its use) sometimes produced deglutitional disorders and aspiration. Eventual recovery in most patients probably results from cicatricial reattachment of suprahyoid muscles to restore laryngeal elevation and closure with swallowing.
The lowered success rate in patients who had a failure of reconstruction before referral (755% good results versus 86%) confirms the intuitive conclusion that the first operation is most likely to succeed. A similar cloud hovered over those patients who underwent prior complex surgical procedures other than segmental resection and reconstruction. A spectrum of increasing failure rates presents: patients with no prior treatment, 3.5%; prior treatment, but not resection and reconstruction, 3.6%; T-tube, 5.0%; prior resection and reconstruction, 5.6%; other complex operations, 9.7%.
In 1986 we 23 detailed the complications of tracheal reconstructions in 365 patients, operated on for both tumors and stenosis As noted earlier, the formerly troublesome complication of granulation tissue formation has been minimized. Postoperative hemorrhage from the innominate artery can be prevented in most cases. Anastomotic separation and restenosis, although not prevalent, remains one of the most disappointing occurrences. Some complications, occurring in patients who underwent lengthy resections, may be attributed to increased anastomotic tension. Others remain unexplained. We have not identified predictors in this study. Another major problem, laryngeal dysfunction, although also not common, again cautions the surgeon to dissect with extreme care in the region of the recurrent laryngeal nerves and to beware of lengthy resections that necessitate laryngeal release.
Some fatalities may be traced to earlier judgment to operate on patients who required ventilatory support after failed tracheal procedures elsewhere. We do not consider it appropriate to attempt tracheal reconstruction under these circumstances. It must also be remembered that a permanent tracheal T-tube 15 may be the best solution for a patient with extensive tracheal damage that would defy reconstruction.
Appendix: DISCUSSION
Dr. Richard A. Jonas (Boston, Mass.).
When dealing with small infants and neonates requiring tracheal surgery, we have found that cardiopulmonary bypass is particularly useful. It is not necessary to impose any myocardial ischemia, and the entire procedure can be performed with a mild degree of hypothermia. The trachea is exposed between the superior vena cava and the aorta. We have found in more than 20 cases of resection of congenital tracheal stenoses that up to 50% of the trachea can be resected with reconstruction by direct anastomosis. We prefer to use a continuous monfilament absorbable suture such as polydioxanone (PDS). In a laboratory study using young sheep, we found that a continuous technique using polydioxanone resulted in a greater cross-sectional area after several months of growth relative to the alternative technique of interrupted Vicryl sutures. I would appreciate any thoughts you have, Dr. Grillo, regarding the application of cardiopulmonary bypass for tracheal
Dr. Grillo.
In this series of postintubation stenoses we had no occasion to use bypass. It was totally unnecessary and would not have made anything simpler anywhere along the line.
The subject that you were discussing, namely, congenital stenosis in small infants, is totally different. I would hesitate to say much because my experience is minimal. The youngest patient on whom I operated was 3 months of age. Using Goldstraw's technique, 1 the surgeon does not have to approach the trachea between the vena cava and aorta. He or she can approach it from the top down, either with or without upper sternotomy, working behind the vessels where the carina is easily accessible. The procedure can be done very simply and I found no need for bypass. We simply placed a little endotracheal tube in the trachea and, when finished, pulled it out. The patients were just fine. Bypass seemed superfluous.
Footnotes
Read at the Seventy-fourth Annual Meeting of The American Association for Thoracic Surgery, New York, N.Y., April 24-27, 1994. 
References
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