Tracheal Surgery Sina Ercan, M.D. - PowerPoint Presentation

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Tracheal Surgery

Sina Ercan, M.D.

Yeditepe University

Department of Thoracic Surgery

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Lesson: Surgical Pathologies of Trachea and Their Treatment

At the end of this lecture, the student should be able to:

List

the

presenting

symptoms

of

patients

with

tracheobronchial

stenosis

List

the

major

pathologies

of

trachea

Explain

the

main role of

cervicothoracic

somputerized

tomography

and

pulmonary

function

tests

in

diagnosing

tracheal

obstructive

pathologies

Define

the

pathologic

cascade

of

developement

in

postintubation

tracheal

stenosis

Explain

the

initial

evaluation

and

management

of

patients

with

tracheal

stenosis

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Correct terminology

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Tracheal Stenosis Etiology

Benign stenosis

Idiopathic stenosis

Iatrogenic stenosis

Postintubation stenosis

Due to previous surgical interventions

Traumatic stenosis

Benign tumors and pathologies

Malignant stenosis

Primary malignant tracheal tumors

Secondary malignant tracheal tumors

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Terminal tracheal injury due to high cuff pressure

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Diagnosis

Airway obstruction symptoms such as dyspnea, stridor

Patients can be misdiagnosed with asthma and treated for years

Flow-volume loop compression on both phases is typical for airway obstruction

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Flow-volume loop in fixed airway obstrucion

Diagnosis

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Diagnosis

Preop glottic insufficiency to be searched

Preop awake laryngoscopy

Preop work-up for presence of aspiration

Tracheostomy means previous intubation – look for a distal second lesion

Vocal cords do not move both in paralysis and cricoarythenoid arthritis or traumatic ankylosis

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Diagnosis

Stenotic segment calculation to be correct

CT image in supine position may falsly indicate a preglottic stenosis

Overresection – increased anastomotic tension – restenosis

Pediatric trachea tolerates the tension poorly in comparison with adults

Insufficient resection – remaining fibrosis – restenosis

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Tracheomalasia

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Idiopathic Laryngotracheal Stenosis

Mostly in females in 3rd and 5th decades of life

No known intubation history

Fibrotic scar tissue with low inflammation

Acquired (not congenital)

Not coexistent with mediastinal fibrosis or lymphatic involvement

No proven direct relation with acid reflux

May be confused with Wegener

’

s granulomatosis limited to upper airway. This can be ruled out with ANCA test and septal biopsy

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Iatrogenic Laryngotracheal Stenosis

Incorrect tracheostomy applications

Wrong indication

Wrong technique

Wrong care

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Iatrogenic Laryngotracheal Stenosis

Incorrect tracheostomy applications

Wrong indication

Wrong technique

Wrong care

- Wrong technique

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Iatrogenic Laryngotracheal Stenosis

Incorrect tracheostomy applications

Wrong indication

Wrong technique

Wrong care

– Wrong Care

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Iatrogenic Factors

Metal stents in bening tracheal conditions cause elongation of pathologic segment and cause the patient to loose the previously present chance of surgical cure

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Iatrogenic Factors

Continuous suturing technique with nonabsorbable suture material resulting in restenosis

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Suture material preference

Nonabsorbable sutures

More calcification in anastomosis

Protruding into the lumen over time, causing granulation

Absorbable sutures

Monofilament

Multifilament

Suture technique

Interrupted suture in pediatric patients

4/0 sutures in adults and 5/0 in pediatrics

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Restenoz

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Restenoz

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Key Points in Laryngotracheal Resections

Sufficient preoperative work-up and correct diagnosis

Preop ENT consultation: glottic sufficiency?

Posterior commissure interarythenoid stenosis?

If present, such pathologies to be corrected before tracheal resection

Correct approach to be decided and performed tediously with great care

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Key Points in Laryngotracheal Resections

If posterior disection carried above the inferior border of cridoid cartillage then recurrent laryngeal nerves are dangered

Mucosal apposition is critical in healthy healing of anastomosis

In long segment resections a little mucosal irregularity and inflammation can be tolerated however the cartillages should be healthy

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Idiopathic and Postintubation Laryngeal Stenosis

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Laryngotracheal Resection Technique

These resections are different and

more complex

than a regular tracheal resection

Subglottic laryngeal airway is narrow and usually affected by scar formation

Laryngotracheal anastomosis requires

at least 6mm of a healthy distance

beyond the vocal cords

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Laryngotracheal Resection with Posterior Membrane

Especially postintubation stenosis involves cricoid cartillage 360

°

The scar tissue on the posterior cricoid plate needs to be excised

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Komplikasyonların Tedavisi

Vokal kord disfonksiyonu

Geçici

Kalıcı

Risk faktörleri:

Krikoid etrafında yoğun skar dokusu

Laringotrakeal rezeksiyon

Karinal R&R

Maling neoplazm rezeksiyonları

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Komplikasyonların Tedavisi

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Complications in Laryngotracheal Resections

Vocal cord problems and deglution problems can be symultaneous

Deglution problems usually seen following release techniques

Thyrohyoid > suprahyoid release

Also after;

Long segment resection

Advanced age

Presence of neurological problems

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Complications in Laryngotracheal Resections

Laryngeal edema is more common after laryngotracheal resection

Postextubation wheezing and stridor

Edema can be differentiated from cord paralysis by examining under mild anesthesia

In edema a #5.5 – 6 ETT is placed and kept in trachea for a few days, then extubate

If edema continues then tracheostomy placed

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Treatment of Complications

Best treatment is to prevent the complications

In tracheal surgery the best chance lies in the first surgery

A T-tube providing a sufficient airway sometimes to be prefered over a risky resection and reconstruction

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Treatment of Complications

Minimal aspiration is normal in elderly

If preoperative aspiration was serious and resistant to treatment then a permanent tracheostomy is the right treatment

Postoperative aspiration may improve with physiotherapy over time

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Treatment of Complications

A significant complication of laryngotracheal resections is uni- or bilateral vocal cord paralysis

This may improve over time

If persistant, then the cord is fixed in such a position that, it will allow enough phonation while not limiting the breathing

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Treatment of Complications

Nonabsorbable sutures cause more granulation tissues

Rijid bronchoscopy can be used to excise the protruding suture material and granulation

Triamcinolone and methylprednisolone injection results are variable

Mitomycin-C can be used to inhibit fibroblastic activity

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Conclusions

Success in tracheal surgery is highly

volume dependent

and not appropriate for occasional performance

Preop evaluation is not with only CT but should include physiologic, anatomic and endoscopic evaluation

A

dedicated anesthesiologist and an ENT specialist

to be included in the team

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Conclusions

Proper infrastructure

and surgical tools to be available

Flexsible and rigid endoscopy sets

Fast track laryngeal mask

Jet ventilator

A collection of different size and model T-tubes and tracheostomy tubes

The surgeon to be competent in the old and current literature knowledge and he should always have a

B and even a C plan

in mind