Ann Thorac Surg 2008;85:1500. doi:10.1016/j.athoracsur.2007.07.079
© 2008 The Society of Thoracic Surgeons
Correspondence
Technical Standpoints in Tracheal Surgery
Francesco Puma, MD,
Mark Ragusa, MD, FCCP
Department of Thoracic Surgery, University of Perugia Medical School, Chirurgia Toracica, Ospedale Civile S. Maria, Terni, 05100 Italy
(Email: francescopuma{at}aospterni.it).
To the Editor:
We read with great interest the article by Abbasidezfouli and colleagues [1]. The authors reported their extensive experience in the treatment of postintubation tracheal damage, focusing on the challenging treatment of multi-segmental tracheal stenoses (MTS).
Several concepts in this article are to be considered as a matter of debate:
- 1 First, MTS is not an uncommon problem when a cuff stricture is associated with a stomal lesion [2]. If the extent of the disease is not too long, then immediate surgical repair is indicated, including both the stenotic sites. Such a condition occurs rather frequently. If there is a long distance between the two strictures, MTS is a difficult problem to solve. As we previously reported, silicone stents are a reasonable alternative to resection in patients who are inoperable for extended tracheal damage [3].
- 2 In the article [1], the authors report up to 9 cm of tracheal resection, which is certainly both an exceptional and an unsafe procedure. Technical details on this extraordinary operation could be useful to understand how the anastomotic tension was avoided.
- 3 In staged resection, Abbasidezfouli and colleagues [1] first operated on the more troublesome stricture. This concept elicits some doubts. When indicated, the first resection must involve the distal stenosis with a short T-tube placed in the proximal lesion [2]. If one of the strictures is not significant, as reported by the authors [1], there should be no reason to resect it.
- 4 The timing of the staged resection reported in the article is questionable. We think that performing the second resection one month after the first procedure is too risky, because even a rigid bronchoscopy could be dangerous in an uncomplicated, freshly operated trachea. Grillo indicated that the second tracheal resection must be delayed for at least 4 months [2].
- 5 Mortality reported in this series mainly seems to be related to an erroneous management of a T-tube. The T-tube is a safe device if the patient is adequately informed about its care. Obstruction is possible early after insertion, but once the tube is well tolerated for a couple of months, then late problems are unlikely to occur [4]. Furthermore suctioning is possible trough the external sidearm of the tube, and in an emergency it can easily be pulled out. In the long-term, the T-tube becomes unsafe only if it is left uncapped, but this event should probably be considered poor management.
In our opinion this article, although interesting, provides multiple messages in contrast with the currently accepted principles in tracheal surgery.
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References
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- Abbasidezfouli A, Shadmehr MB, Arab M, et al. Post intubation multisegmental tracheal stenosis: treatment and results Ann Thorac Surg 2007;84:211-214.[Abstract/Free Full Text]
- Grillo HC. Surgery of the trachea and bronchiOntario, Canada: BC Decker Inc; 2003. pp. 522-531.
- Puma F, Ragusa M, Avenia N, et al. The role of silicone stenting in the treatment of cicatricial tracheal stenoses J Thorac Cardiovasc Surg 2000;120:1064-1069.[Abstract/Free Full Text]
- Gaissert HA, Grillo HC, Mathisen DJ, Wain JC. Temporary and permanent restoration of airway continuity with the tracheal T-tube J Thorac Cardiovasc Surg 1994;107:600-606.[Abstract/Free Full Text]
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- Azizollah Abbasidezfouli
Ann. Thorac. Surg. 2008 85: 1500-1501.
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A. Abbasidezfouli
Reply
Ann. Thorac. Surg.,
April 1, 2008;
85(4):
1500 - 1501.
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