1. Tracheal Surgery Sina Ercan, M.D. Yeditepe University Department of Thoracic Surgery

2. 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

4. Correct terminology

11. 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

14. Terminal tracheal injury due to high cuff pressure

20. 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

21. Flow-volume loop in fixed airway obstrucion Diagnosis

22. 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

23. 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

24. Tracheomalasia

25. 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

31. Iatrogenic Laryngotracheal Stenosis Incorrect tracheostomy applications –Wrong indication –Wrong technique –Wrong care

32. Iatrogenic Laryngotracheal Stenosis Incorrect tracheostomy applications –Wrong indication –Wrong technique –Wrong care -- Wrong technique

36. Iatrogenic Laryngotracheal Stenosis Incorrect tracheostomy applications –Wrong indication –Wrong technique –Wrong care – Wrong Care

44. 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

48. Iatrogenic Factors Continuous suturing technique with nonabsorbable suture material resulting in restenosis

49. 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

50. Restenoz

53. 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

54. 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

55. Idiopathic and Postintubation Laryngeal Stenosis

56. 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

65. Laryngotracheal Resection with Posterior Membrane Especially postintubation stenosis involves cricoid cartillage 360° The scar tissue on the posterior cricoid plate needs to be excised

69. Komplikasyonların Tedavisi Vokal kord disfonksiyonu –Geçici –Kalıcı Risk faktörleri: –Krikoid etrafında yoğun skar dokusu –Laringotrakeal rezeksiyon –Karinal R&R –Maling neoplazm rezeksiyonları

70. Komplikasyonların Tedavisi

71. 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

72. 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

73. 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

74. 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

75. 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

76. 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

77. 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

78. 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