Ann Thorac Surg 2008;85:654-656. doi:10.1016/j.athoracsur.2007.08.052
© 2008 The Society of Thoracic Surgeons
Case Reports
Total Tracheal Resection for Long-Segment Benign Tracheal Stenosis
Jia Lin Soon, MRCS*,
Thirugnanam Agasthian, FRCS
Department of Cardiothoracic Surgery, National Heart Centre, Singapore
Accepted for publication August 22, 2007.
* Address correspondence to Dr Soon, Department of Cardiothoracic Surgery, National Heart Centre, Mistri Wing, 17 Third Hospital Ave, Singapore, 168752, Singapore (Email: soon.jia.lin{at}singhealth.com.sg).
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Abstract
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Tracheal resection for long benign tracheal stenosis is challenging because of the lack of a suitable replacement to facilitate tension-free anastomosis. We describe a patient with a 6-cm post-tuberculous tracheal stricture, severely debilitated post-recurrent bronchoscopic intervention. Staged resection facilitated near-total tracheal resection with primary anastomosis and complete symptom resolution.
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Introduction
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Tension-free anastomosis after resection of long tracheal stricture seems to be a paradox. However, in the absence of a suitable replacement for the trachea, this remains the primary goal of surgery.
A 39-year-old woman presented with post-tuberculous tracheal stricture. She had a tracheostomy for tuberculosis at age 22. Four years ago, she had 80% tracheal stenosis 2 cm distal to the vocal cords with further stenotic web rings beyond. Tracheal stenting was performed a year later for dyspnea. The stent was removed 3-years post-insertion, but her symptoms promptly recurred with re-stenosis by granulation tissue and fibrotic scar, extending from the T1–T4 spinal level, with mild right main bronchus narrowing (Fig 1A). Mild coryzal symptoms with mucus production would trigger stridor, resulting in recurrent admissions for bronchoscopic dilatation or laser ablation.
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Fig 1. (A) Three-dimensional reconstructed image of tracheal stenosis extending from 2 cm distal to the vocal cords to the T4-spinal level. (B) Sagittal computed tomographic image of residual trachea after initial resection (top of C7 to bottom of T2 vertebra) with recurrent stenotic segment ending at the carina.
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Tracheal resection was performed in November 2005 using the transternal transpericardial approach. The 6-cm stenotic segment starts 2 cm below the vocal cord and extends to just above the carina. The tightest point (5-mm diameter) was 3 cm above the carina (Fig 2). Hilar release and mid-distal tracheal mobilization, with cross-field ventilation through the left main bronchus facilitated 4 cm tracheal resection. The abnormal but less stenotic proximal trachea was split longitudinally at its distal end to widen the lumen for end-to-end anastomosis to the distal trachea above the carina. The anterior defect was patched with pericardium.
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Fig 2. Top panel: the 5-mm diameter stenosis approximately 3 cm above the carina requiring bronchoscopic dilatation to allow passage of the flexible bronchoscope. Bottom panel: widely patent trachea (4-cm residual length) and anastomosis post-resection.
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Postoperative nasogastric tube feeding and bilateral chin-to-chest sutures were continued for 8 days until bronchoscopy confirmed anastomotic healing. Unilateral vocal cord palsy was noted. She was discharged from the hospital 14 days post-resection. Dyspnea recurred a week later, secondary to anastomotic line granulation tissue (5-mm luminal diameter, at the site of the pericardial patch).
Despite oral steroid and mucolytic therapy, she returned every 2 weeks feeling "tight" with improvement post-bronchoscopic dilatation to 7-mm diameter. Three months post-resection, she required less frequent, but nevertheless regular, outpatient bronchoscopic dilations (Fig 1B). She slept at night with continuous positive airway pressure. Six months post-surgery, 3 cm of narrowed trachea remain (5-mm diameter at the tightest point). In view of her debilitating symptoms, we procured an aortic homograft in anticipation of radical resection.
A neck collar incision with upper partial sternal split was performed. Trachea was again mobilized. Suprahyoid tracheal release and neck flexion allowed for further tracheal resection at the previous anastomosis (3 cm resected) until healthy trachea was identified. Primary anastomosis was easily performed at the carina. She was extubated the following day. Bilateral vocal cord palsy was noted. Nasogastric tube feeding was subsequently weaned, and full oral diet resumed on postoperative day 21.
Bronchoscopy measured a 4-cm residual trachea length with a 1-cm luminal diameter 5 months post-resection (Fig 2). Her vocal cord palsy improved with expectant treatment 9 months later. She remains symptom-free 15 months later with markedly improved lung function (Fig 3).
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Fig 3. Spirometry with flow-volume loop of patient showing complete resolution of the severe obstructive pattern post-tracheal resection. Left panel: preoperative; right panel: postoperative. Volume (L) in the x-axis, and flow (L/sec) in the y-axis. Outer line of expiratory limb marks predicted values with confidence interval. (FEV1 = forced expiratory volume in 1 second; FVC = forced vital capacity; PEF = peak expiratory flow; Postop = postoperative; Preop = preoperative; * = actual value measured.)
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Comment
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Greater than 50% of the trachea can be resected with primary anastomosis [1, 2]. Pretracheal plane tracheal mobilization and cervical flexion suffices in most patients undergoing 2 to 3 cm tracheal resection. Additional 1.5-cm upper tracheal length is gained with the Montgomery suprahyoid release [3]. Further intrathoracic tracheal length is gained by right hilar (or bilateral hilar) release [4], comprising inferior pulmonary ligament division and "U-shaped" pericardial incision around the inferior pulmonary vein.
The ideal tracheal prosthesis satisfying all of Belsey’s criteria (ie, lateral rigidity, vertical flexibility, airtight lumen, reliable healing, and respiratory epithelial lining) remains elusive [5]. Tracheal allograft reconstruction, although successful [6], is not widely available. Cryopreserved aortic homograft described by Chahine and colleagues [7] is more readily available.
Our patient highlights the problem of stent migration and chronic mucosal abrasion, converting a short stricture to a problematic long one. Anastomotic granulation with re-stenosis, despite pericardial patch and steroids, led to our initial failure. However the interim at 6 months allowed for the establishment of a dense peritracheobronchial fibrotic scar. The carina of the patient had adapted to its new, more cranial position (Fig 1B). The subsequent operation on the proximal trachea was in "virgin" territory superiorly. Generally we use bipolar diathermy for tracheal mobilization to minimize nerve damage. Our "inadvertent" staging of the procedures had facilitated near-total tracheal resection without an interpositional graft, and it cured the patient.
We believe this approach adds to our therapeutic options in benign long-segment tracheal stenosis. We favor the median sternotomy for lower tracheal and carinal surgery, as it facilitates easier access to bilateral bronchus for cross-field ventilation and bilateral hilar "release." It also allows for extension superiorly to a neck skin crease incision and supra-laryngeal release for a single-stage procedure.
In conclusion, resection for long tracheal stenosis is plagued with the problem of a lack of a suitable replacement to facilitate tension-free anastomosis. For this reason, we believe that symptomatic short segment strictures should be referred for surgery without trial of stenting. We report a successful staged near-total tracheal resection of a long stricture with primary anastomosis.
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References
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- Pearson FG, Todd TR, Cooper JD. Experience with primary neoplasms of the trachea and carina J Thorac Cardiovasc Surg 1984;88:511-518.[Abstract]
- Regnard JF, Fourquier P, Levasseur P. Results and prognostic factors in resections of primary tracheal tumors: a multicenter retrospective studyThe French Society of Cardiovascular Surgery. J Thorac Cardiovasc Surg 1996;111:808-814.[Abstract/Free Full Text]
- Montgomery WW. Suprahyoid release for tracheal anastomosis Arch Otolaryngol 1974;99:255-260.[Abstract/Free Full Text]
- Newton JR, Grillo HC, Mathisen DJ. Main bronchial sleeve resection with pulmonary conservation Ann Thorac Surg 1991;52:1272-1280.[Abstract/Free Full Text]
- Belsey R. Resection and reconstruction of the intrathoracic trachea Br J Surg 1951;38:200-205.
- Herberhold C, Franz B, Breipohl W. Chemisch-konservierte menschliche Trachea als Prothesenmaterial zur Deckung trachealer Defekte Laryng Rhinol 1980;59:453-457.
- Chahine AA, Tan V, Ricketts RR. Use of the aortic homograft in the reconstruction of complex tracheobronchial tree injury J Pediatr Surg 1999;34:891-894.[Medline]
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Abstract
Introduction
