Adult Chest Surgery

Chapter 44. Overview 

The upper airways are defined as the trachea and main stem bronchi. Functionally, the upper airways serve as conduits for ventilation. Anatomically and physiologically, however, they represent complex structures that are susceptible to a wide variety of processes. Involvement of the trachea, main stem bronchi, or both in various disease processes, although rare, present challenging problems for both physician and patient.

ANATOMY AND PHYSIOLOGY

The adult human trachea begins at the level of the cricoid cartilage and extends to the bifurcation of the main stem bronchi (Figs. 44-1 and 44-2). The carinal spur is a useful landmark that denotes the distal extent of the trachea. On average, the adult human trachea measures 11 cm in length, with some variation in proportion to the height of the individual patient. There are approximately two tracheal rings per centimeter of trachea. Thus, on average, the total number of tracheal rings ranges from 18–22, with the cricoid forming the only complete tracheal ring. The potential for presentation of the trachea in the neck is a major factor permitting relatively easy surgical access. In a young, nonobese adult, hyperextension of the neck may deliver more than 50% of the trachea into the neck, thereby greatly facilitating any attempt at resection and reconstruction. From a nearly subcutaneous position at the level of the cricoid, the trachea courses posteriorly and caudally at an angle, resting against the esophagus and vertebral column at the level of the carina.

Figure 44-1.

 

The trachea begins at the level of the cricoid cartilage and extends to the bifurcation of the mainstem bronchus.

 

Figure 44-2.

 

Side view of the extent of the trachea.

 

The blood supply of the trachea is vital to successful resection and reconstruction. The upper trachea is principally supplied by branches of the inferior thyroid artery, whereas the lower trachea is supplied by branches of the bronchial artery as well as by branches of the subclavian, supreme intercostals, internal thoracic, and innominate arteries1 (Fig. 44-3). These vessels supply the trachea through lateral pedicles of tissue, and the longitudinal anastomoses between the vessels are very thin. Excessive disruption of these lateral vessels by circumferential dissection of the trachea may compromise blood supply and lead to complications, such as stenosis and anastomotic dehiscence. At the level of the second and third tracheal rings, the thyroid isthmus crosses the trachea anteriorly. The recurrent laryngeal nerves course in a groove between the trachea and esophagus (Fig. 44-4). The nerves enter the larynx between the cricoid and thyroid cartilages.

Figure 44-3.

 

The blood supply of the upper trachea is supplied by branches of the inferior thyroid artery, whereas the lower trachea is supplied by branches of the bronchial artery as well as by branches of the subclavian, supreme intercostals, internal thoracic, and innominate arteries.

 

Figure 44-4.

 

Anatomic configuration of the left recurrent laryngeal nerve.

The trachea bifurcates into the right and left main stem bronchi at about the level of the seventh thoracic vertebra. The right mainstem bronchus arises in a direct line with the trachea, whereas the left mainstem bronchus arises at a sharper angle. This anatomy helps to explain the more frequent right-sided location of aspirated material(s).

The length of the right mainstem bronchus from the trachea to the point of the takeoff of the right upper lobe bronchus is approximately 1.2 cm. The length of the left mainstem bronchus is approximately 4–6 cm from the trachea to the takeoff of the left upper lobe bronchus. Both main stem bronchi are supplied directly by bronchial arteries.

Most commonly, the trachea is approached through a cervical neck incision. As noted earlier, up to 50% of the entire trachea may be accessed in this manner. The right and left main stem bronchi are usually approached through a right posterolateral thoracotomy. The carina may be approached through a right posterolateral thoracotomy or a median sternotomy.

ETIOLOGY AND NATURAL HISTORY

Diseases affecting the upper airways are rare. Tumors of the trachea and main stem bronchi occur most commonly in adults. Most of the primary tumors are malignant, with the majority representing adenoid cystic carcinoma or squamous cell carcinoma. Benign tumors occur most commonly before the seventh decade of life. They tend to occur sporadically and lead to symptoms secondary to progressive airway obstruction. Nonneoplastic diseases, such as infection, are less common than tumors, although the precise incidence is difficult to discern. Left untreated, diseases affecting the upper airways cause significant morbidity and, in some cases, mortality from airway obstruction.

PRESENTING SIGNS AND SYMPTOMS

Symptoms of upper airway pathology are often subtle and insidious in onset. The rarity of upper airway diseases may delay the suspicion of airway pathology as the cause of an individual patient's symptoms. Shortness of breath is the most common symptom experienced by patients who are affected by disease of the upper airways.2 When a tumor or mass is present, the dyspnea occurs after the effective airway lumen has been narrowed by approximately one-third. Even in the face of significant airway narrowing, the patient will have an apparently normal chest x-ray and often is diagnosed as suffering from "asthma." At times, these patients are treated with steroids for prolonged periods of time before a specific diagnosis, such as a tracheal tumor, is established. As the airway narrows further, the classic symptom of wheezing becomes more prominent. The presence of stridor indicates severe compromise of the airway. Failure to improve on steroid therapy often leads to further workup, at which time a specific upper airway diagnosis is established. Cough is another common symptom and may be secondary to irritation or to ineffective clearance of secretions, leading to pneumonia.

DIFFERENTIAL DIAGNOSIS

The symptoms caused by diseases of the upper airways are common to many processes. Other causes of dyspnea must be considered. These include cardiac causes, such as congestive heart failure, as well as pulmonary causes, such as pulmonary embolus. In addition, a myriad of other common processes, such as chronic obstructive pulmonary disease, must be considered. Wheezing is most commonly a sign of primary reactive airways disease, whereas cough may be caused by pneumonia as well as other processes that irritate the airways. It is important to remember, however, that it is the potentially numerous and far more common processes that produce symptoms similar to those of upper airway diseases that often lead to the delay in diagnosis of upper airways disease.

DIAGNOSTIC TECHNIQUES

The overpenetrated posteroanterior chest x-ray is often the most useful means by which to obtain an excellent view of the trachea and main stem bronchi. The presence of a mass and extent of luminal narrowing may be seen by careful inspection of the tracheal air column. Deviation from midline of the tracheal air column also may be noted on a standard chest film. Furthermore, postobstructive pneumonia may be seen. Although not universally available, tracheal tomograms, as described by Weber and Grillo, provide excellent visualization of the entire upper airways.3 These are particularly useful in planning for resection and reconstruction.

CT scanning permits cross-sectional visualization of the upper airways. The presence of an intraluminal mass is often clearly identified by CT scan. Furthermore, by knowing the distance between cuts, one often can accurately estimate the size of the mass as well as the length of airway involved. Three-dimensional helical CT scanning and reconstructed axial imaging are used to obtain virtual bronchoscopic views of the upper airways, thereby permitting an accurate assessment of airway pathology. The presence of an extrinsic mass that is compressing the airways is also best identified by CT scan. MRI may supply additional information, but it is rarely more helpful than the information obtained by CT scan.

On occasion, especially in cases of extrinsic compression of the airway, a barium esophagram may be useful. Rarely, arteriography may be useful in defining compression of the airway by vascular structures.

Functional studies may provide useful information in the diagnosis of upper airway disease. Pulmonary function studies may point to airway obstruction. A decrease in peak flow rates, as well as a flattening of the expiratory flow-volume loop, may lead to suspicion of an obstructive process if clinical signs have been overlooked. Furthermore, pulmonary function studies may provide information regarding the status of the pulmonary parenchyma. While this may not alter the decision to perform surgery, it may alter the conduct of a given operation, for example, whether or not single-lung ventilation will be tolerated.

Bronchoscopy is mandatory in the evaluation of upper airway disease. If a mass is noted in the airway, bronchoscopy is essential to establishing a histologic diagnosis (i.e., biopsy) and for determining the extent of the mass. If it is necessary to establish an adequate airway by removing a portion of a tumor or to obtain more adequate tissue for diagnosis, then rigid bronchoscopy may be preferable. Bronchoscopy always should be performed by experienced individuals and with appropriate precautions for the possibility of airway compromise. When the indications for surgical resection and reconstruction have been established by other modalities, bronchoscopy may be deferred until the time of the operative procedure.

SPECIFIC DISORDERS

Tumors

CHONDROMA

Chondroma is the most common benign mesenchymal tumor of the upper airways.4 Histologically, chondromas resemble normal cartilage and can exhibit vascular invasion. Approximately 200 cases have been reported in the world literature. and there is a 5:1 male predominance. Most patients present in adulthood.

Grossly, the tumor appears as a firm, white nodule that projects into the lumen of the airway (Fig. 44-5). The most common site of origin is the internal aspect of the posterior cricoid lamina. These tumors are covered by a normal mucosa, and calcification is present in up to 75% of the patients. The firm consistency of the tumor may make it difficult to obtain a biopsy. No clear etiology for these tumors has been described. Although these tumors can be removed bronchoscopically, local recurrence has been observed. There also have been reports of malignant transformation. For these reasons, the recommended treatment is segmental resection with a rim of normal tissue.5

Figure 44-5.

 

Bronchoscopic view of chondroma located in main trachea.

GRANULAR CELL TUMOR

Granular cell tumors (GSTs) can occur in any organ. The most common site of occurrence is the tongue. Burton and colleagues conducted a 50-year review of the literature and reported only 30 cases of tracheal GST.6 In a 10-year review of all reported cases in the Netherlands, only four cases of upper airway GST were found.7 These tumors occur predominately in women, with a racial predominance in blacks. In the airway, the majority of GSTs are located in the cervical trachea. The tumors are solitary in 80% of patients.

Although originally thought to be derived from skeletal muscle, GSTs are now thought to be of neurogenic origin, probably from the Schwann cell. Histologically, these tumors consist of round cells with centrally placed nuclei. Characteristically, these tumors stain positive for the S-100 protein, a protein found in the central nervous system, primarily in neurons. They also have a distinct tendency for local invasion into surrounding tissues, and malignant transformation has been reported in 1–2% of GSTs. However, malignant transformation has never been reported in the trachea.

The mainstay of therapy for GSTs of the upper airways is surgical excision. However, there is no clear agreement regarding the extent of excision. Daniel and colleagues found that tumors larger than 1 cm had an increased risk for full-thickness wall involvement and therefore an increased risk of local recurrence after bronchoscopic excision.8 Therefore, they recommend segmental airway resection for GSTs larger than 1 cm. Because of the risk of recurrence, all patients with excised GSTs should undergo serial bronchoscopic examination for several years.

SQUAMOUS CELL PAPILLOMA

Solitary squamous cell papilloma arising in the upper airways is quite rare. Although it is the most common benign tumor of the larynx, the largest review of the literature reported only 55 cases involving the tracheobronchial tree.9 These tumors occur predominately in males, and there is a strong association with a history of smoking. Papillomas are easily excised bronchoscopically, and this is the preferred method of excision. Surgical resection is reserved for patients in whom the tumor is wide-based, there is suspicion of malignancy, or the tumor is located in an area that makes endoscopic removal difficult.

GLOMUS TUMOR

These tumors most commonly involve the skin of the extremities. When located in the tracheobronchial tree, the trachea is the most frequent site of involvement. The most recent review of the world literature revealed only 16 reported cases of glomus tumor of the trachea.10 These tumors are composed of smooth muscle cells, which are similar to those of the glomus body. Although there are malignant variants, these tumors are benign in most of the reported cases. There is a male predominance, and the average age at diagnosis is 58 years. The preferred treatment is segmental resection with primary reconstruction.

NEUROFIBROMAS

Only 23 cases of tracheobronchial neurofibromas have been reported.11 These tumors are usually multiple, not encapsulated, occur within the nerve sheath, and contain neuritis. They are frequently associated with von Recklinghausen's neurofibromatosis, and up to 12% may undergo malignant transformation. Small tumors may be excised bronchoscopically, with or without laser ablation of the base of the tumor. However, larger tumors or those that appear to invade or obstruct should be removed by formal surgical resection.

OTHER TUMORS

A number of other rare tumors have been reported in the upper airways. Hemangioma may be found in the trachea. Often, hemangiomas will regress spontaneously and require no treatment. However, small doses of both radiation and steroids have been used to cause regression. Fibrous histiocytoma is a histologically benign tumor that can be locally invasive. The term inflammatory pseudotumor is sometimes used to describe this tumor as a consequence of the associated prominent inflammatory component. Although fibrous histiocytoma tends to have a benign behavior in the upper airways, resection is recommended owing to its local infiltration. Lipoma, hamartoma (Fig. 44-6), and leiomyoma also have been reported in the upper airway. Case reports of tracheal myxoma as well as intratracheal thyroid have been published.

Figure 44-6.

 

Bronchoscopic view of hamartoma in segmental bronchus.

Infectious/Inflammatory Disease

The upper airways may become involved in a variety of disease processes, often secondary to a more systemic illness. Relapsing polychondritis is a disease of unknown origin in which any cartilaginous structure in the body may be affected, most commonly the nose and ears. When the upper airways are involved, patients experience progressive airway obstruction and difficulty in clearing secretions. The disease has a variable course, and therapy is usually limited to palliative stenting.

Wegener's granulomatosis is a systemic inflammatory disease that may involve the upper airways and lead to obstruction. Treatment is focused primarily on the systemic disease. Similarly, amyloidosis at times may affect the upper airways, leading to obstruction. Sarcoidosis may affect the upper airways by causing extrinsic compression from enlarged mediastinal lymph nodes or by causing extensive fibrotic changes within the airway, leading to stenosis and obstruction. Treatment is focused on the underlying condition because the airway process is usually too extensive and diffuse to permit surgical resection. Tracheopathia osteoplastica is a disease characterized by the formation of calcified nodules beneath the mucosa adjacent to but not involving the cartilages. It has a variable course and rarely requires surgical treatment.

Tuberculosis may involve the upper airways. Acutely, patients may be affected by tracheitis; as this process heals after medical treatment, a stenosis may develop. On rare occasions, segmental resection may become necessary. However, this should be performed only long after the active process is controlled. Histoplasmosis also may affect the upper airways, principally by causing extrinsic compression. The dense mediastinal fibrosis, as well as the enlarged and hardened mediastinal lymph nodes, may lead to compression of the distal trachea, carina, and main stem bronchi. Additionally, broncholiths may be seen within the airway as a result of erosion of a lymph node. Involvement of the upper airways by cicatricial pemphigoid also has been reported.

Extrinsic Compression

VASCULAR RINGS

A number of congenital vascular anomalies may lead to extrinsic compression of the upper airways. These anomalies typically present in infants or young children and nearly always require surgical correction because of airway obstruction (see Chap. 38). A double aortic arch is the most common complete vascular ring that causes tracheal compression. Anatomically, this anomaly is characterized by an ascending aorta that divides into two arches. The two arches pass around the esophagus and trachea and then rejoin posteriorly to form the descending aorta. Usually, one of the arches is dominant, most commonly the right one. Affected patients typically present in the first year of life with stridor, respiratory distress, and a characteristic seal bark cough. The diagnosis is made by barium esophagogram in the appropriate clinical setting. In addition, a CT scan or MRI may be obtained. The treatment is surgical division of the nondominant portion of the double arch at its insertion into the descending aorta, thereby releasing the complete ring. The ligamentum arteriosum, as well as any adhesions around the trachea and esophagus, is also divided. The results of surgery are excellent, with complete resolution of both respiratory and esophageal symptoms.

A right aortic arch with a left ligamentum arteriosum also may form a complete ring and lead to compression of the airway and esophagus. In this anomaly, which may have several variations, the compression is not as severe as with double aortic arch; this may lead to a later onset of symptoms and therefore presentation. The diagnosis is established in a similar manner to double arch. Treatment is also surgical, with division of the ligamentum and release of the ring. Results are excellent, and nearly all patients are relieved of their symptoms 1 year after treatment.

Rarely, the innominate artery may cause anterior compression of the trachea. This anomaly is seen when the innominate appears to originate from a more posterior location on a normally located aortic arch. The diagnosis is usually suspected on CT scan and can be confirmed by rigid bronchoscopy. Surgical treatment, when indicated, attempts to achieve relief of the anterior compression by suspending the innominate artery to the posterior aspect of the sternum.

A pulmonary artery sling is characterized by a left pulmonary artery that originates from the right pulmonary artery. As the anomalous pulmonary artery courses anteriorly to the esophagus to the hilum of the left lung, a ring is formed that encircles the right mainstem bronchus and distal trachea. In addition to the extrinsic compression, approximately 50% of patients with this anomaly will have complete tracheal rings, leading to severe airway stenosis. Nearly all patients with pulmonary artery sling present in early infancy with respiratory distress, which may be particularly severe if complete tracheal rings are also present. The diagnosis is suspected by the observation of hyperaeration of the right lung on plain chest radiograph as well as with anterior compression of the esophagus on barium esophagogram (all other lesions show posterior compression). Both CT scan and MRI may confirm the diagnosis. However, echocardiography is the current modality of choice for making the diagnosis. Echocardiography has been shown to be very accurate and obviates the need for any sedation in an infant whose respiratory status may be tenuous at best. Treatment is always surgical. Although several approaches have been described, surgical correction is usually achieved using cardiopulmonary bypass.12 The left pulmonary artery is divided and reimplanted into the main pulmonary artery anterior to the trachea. In the presence of complete tracheal rings, a simultaneous tracheoplasty may be performed.

CONGENITAL TRACHEAL STENOSIS

Congenital tracheal stenosis is a rare but life-threatening disorder characterized by congenital absence of the membranous trachea. The trachea is composed of complete cartilaginous O rings, and although the length may vary, this most frequently leads to long-segment tracheal stenosis. The type of stenosis is classified into three categories and may involve the main stem bronchi as well. In one report, the medical management of this entity resulted in a greater than 40% mortality.13

The diagnosis is suspected on clinical grounds. These patients present in the first months of life with severe respiratory distress. The diagnosis is confirmed and the extent of airway involved is assessed by rigid bronchoscopy. Since these patients frequently have other malformations, such as pulmonary artery sling and/or cardiac abnormalities, it is important to perform a thorough diagnostic evaluation prior to undertaking any surgical repair of the airway.

As alluded to earlier, treatment is surgical correction. For short-segment stenosis, segmental resection and reconstruction are sufficient to achieve long-term patency of the airway. Wright and colleagues have reported that resection of more than 30% of the pediatric airway results in a substantial failure rate.14 For long-segment stenosis, a number of surgical options have been devised, including pericardial patch tracheoplasty and slide tracheoplasty. Surgical correction of the stenosis may be made more difficult by the need to correct other anomalies in the same setting (e.g., pulmonary artery sling).

GOITER

Large goiters, particularly those with a significant posterior component, may compress the airway. The goiter may alter the shape of the airway over a prolonged period of time, leading to some compromise in the lumen of the airway. In rare instances, the compression may lead to softening of the tracheal cartilages, resulting in a malacic airway. The diagnosis of compression is made by bronchoscopy. Surgical resection of the compressing goiter results in significant improvement in respiratory symptoms. However, if malacia has occurred, care must be exercised, for removal of the goiter actually may remove an element of support for the airway and therefore lead to airway collapse.

POSTPNEUMONECTOMY SYNDROME

This rare entity occurs most commonly after right pneumonectomy. The mediastinum shifts to the right and may lead to angulation and compression of the remaining airway. Typically, the carina and left mainstem bronchus are compressed by the left pulmonary artery anteriorly and the aorta or vertebral column posteriorly. The syndrome also may occur in a reverse manner in the presence of a right aortic arch. The diagnosis is made by cross-sectional imaging and bronchoscopy in the appropriate clinical setting. Surgical treatment involves mediastinal repositioning, as reported by Grillo and colleagues.15

Posttraumatic Disorders

PENETRATING TRAUMA

The upper airways, like any other organ in the body, may be involved by penetrating trauma. Gunshot wounds to the neck that involve the airway are often fatal. When not fatal, the airway injury is usually a laceration. Penetrating knife wounds to the neck area may cause tracheal laceration. Diagnosis is made on clinical grounds. Respiratory distress, subcutaneous emphysema, and the presence of a neck wound should strongly raise the suspicion of an airway injury. In the chest, the presence of a pneumothorax with a transmediastinal missile also should raise suspicion of airway injury. After ensuring a secure airway, bronchoscopy is mandatory for evaluation. Depending on the degree of associated injuries, the airway laceration simply may be repaired primarily with absorbable suture; the repair should be buttressed with viable tissue. In rare circumstances, segmental resection and reconstruction may be required.

BLUNT TRAUMA

Blunt trauma also may cause significant damage to the upper airways. At times, this damage may go undetected for prolonged periods of time. Ruptures of the airways may not be recognized at the time of initial presentation and may be detected only when the airway has become stenotic with time. The stenoses usually are severe and may compromise the distal airways. The diagnosis is made by bronchoscopy in the appropriate clinical setting, and the treatment is resection of the stenosis with reconstruction as soon as possible.

Total tracheal disruption is an often fatal injury. However, some patients survive and are treated with emergent tracheostomy. The recurrent laryngeal nerves are usually damaged, sometimes permanently. With time, the area of separation becomes severely stenotic. Although difficult, reconstitution of a suitable airway may be accomplished.

POSTINTERVENTION LESIONS

The upper airways may incur damage as a result of attempted therapeutic interventions. Segmental resection and reconstruction may result in anastomotic stricture, particularly if the blood supply has been damaged. Radiation therapy may result in inflammation, fibrosis, and ultimate stenosis of the airway. Laser and burn injuries to the airways also may lead to fibrosis and stenosis. The placement of stents, particularly self-expanding metal stents, may result in strictures and granulations of the airway.

The airway may be damaged as a result of intubation. The damage may be caused by standard nasal or oral endotracheal tubes or from tracheostomy tubes. Although a number of lesions may be seen, the most common are those that lead to airway obstruction. Stenosis occurs at the site of the cuff and may be seen as a result of a period of intubation as short as 2 days. The damage and resulting stenosis occur as a result of pressure necrosis on the tracheal wall by an overinflated cuff. In patients who have undergone tracheostomy, granulations may occur at the tracheostomy site as well, also leading to obstruction. Symptoms may occur as early as 2 days after extubation but may occur up to several months after extubation. The diagnosis requires a high index of suspicion in these patients, often for prolonged periods of time, owing to a delay in diagnosis. Every patient who develops symptoms of airway obstruction and who has a history of being intubated for over 24 hours or more within the previous 2 years must be suspected of having an airway stenosis.16 Although treatment must be individualized, these lesions are often amenable to successful segmental resection and reconstruction.

THERAPEUTIC OPTIONS

In general, all patients diagnosed with benign upper airway disease require treatment, especially in the presence of symptoms. The management of these patients, however, must be individualized. Diffuse processes such as Wegener's granulomatosis or an infectious process should be managed medically by treating the underlying process. In some circumstances (e.g., small localized tumor), bronchoscopic excision may be satisfactory. The use of airway stenting for benign upper airway disease has become more common. The use of silicone stents in benign tracheobronchial stenoses has been reported.17 These stents are particularly useful in long-segment stenoses, which may not be amenable to surgical resection. Self-expanding metallic stents also have been used.18 Gaissert and colleagues, however, strongly cautioned against the use of such metal stents for benign tracheobronchial pathology.19

In most cases, surgical resection remains the mainstay of management. Most patients will have discrete pathology that is amenable to resection and reconstruction. For these patients, surgical resection and reconstruction offer excellent long-term results.

TECHNIQUE OF SEGMENTAL RESECTION AND RECONSTRUCTION

If surgical intervention is indicated, a detailed and specific plan must be developed before undertaking any attempted resection and reconstruction of the upper airway. The best opportunity for a successful outcome is at the initial operation; this fact must be kept in mind by any surgeon who attempts to perform such procedures. If any doubt exists regarding either the surgeon's or the institution's ability to perform resection and reconstruction, then it is wisest to refer the patient to another surgeon or institution with experience in the management of upper airway diseases. A thorough knowledge of the techniques of management of the upper airway, the anatomy, the methods of obtaining a tension-free anastomosis, and the acceptable types of repair are mandatory for the optimization of a successful outcome. Control of the airway is of paramount importance in the management of upper airway obstruction. Obstruction of the upper airway may make standard endotracheal intubation impossible. Control of the airway is best accomplished in the OR, where an assortment of rigid bronchoscopes, dilators, biopsy forceps, and instruments for emergency tracheotomy are readily available. Anesthesia is accomplished by inhalational induction, and paralytic agents are avoided. After initial evaluation, an adequate airway is established and secured prior to commencement of resection.

Positioning of the patient for surgery is also critical, for this must permit full access to the operative field. For lesions in the upper half of the trachea, a cervical collar incision is used; this incision may be extended to the upper portion of the sternum if access to the mediastinal trachea is necessary. Lesions in the lower trachea and main stem bronchi are optimally approached through a right posterolateral thoracotomy. It is important to note that the entire operative field must be prepped for the possibility of extension of any individual incision.

The airway is approached above and below the lesion (e.g., tumor), and these areas are cleared first. Dissection remains close to the trachea, and as long as dissection is maintained on the surface of the trachea, the recurrent laryngeal nerves are safe and need not be identified. Circumferential dissection of the airway over a distance greater than 1–2 cm away from the point of transaction is to be avoided because this may compromise blood supply and lead to problems with healing and stenosis. Once the area to be resected has been identified, the entire pretracheal plane is freed bluntly to the carina and often down the proximal mainstem bronchus. Once the inferiormost extent of resection is identified, midlateral traction sutures of 2-0 Vicryl are placed through the full thickness of the wall of the airway approximately 1–2 cm distal to the anticipated line of transaction. Preparations then are made for transaction. Sterile connecting tubing is passed to the anesthesiologist, and a sterile cuffed endotracheal tube (flexible armored Tovell tube) is brought into the operative field. The airway is opened in a transverse manner immediately distal to the inferior aspect of the lesion to be removed, and the lumen is carefully inspected. If the chosen level is deemed satisfactory, transection is completed; if not, then a more distal level of transection is chosen. After the airway has been transected distally, it is intubated across the field with the flexible endotracheal tube while the orotracheal tube is withdrawn to a level proximal to the anticipated proximal transection point. It is wise to suture a catheter to the tip of the orotracheal tube to ensure that if it is withdrawn above the vocal cords, it may be reintroduced with ease back into the airway.

The transected distal airway is now grasped with forceps, and gentle traction is exerted to facilitate proximal dissection. Once an appropriate level for proximal transaction has been chosen, traction sutures are placed in the proximal airway in a manner similar to that described for the distal airway. The airway then is transected, and attention is directed to reconstruction.

After the specimen is removed, the previously placed traction sutures are gently drawn together to ensure lack of tension on the proposed anastomosis. In the trachea, this is usually done with some degree of neck flexion as the sutures are temporarily drawn together. Excessive tension should be avoided because this will markedly increase the likelihood of complications. If there is undue tension, the surgeon should be familiar with various release maneuvers (e.g., suprahyoid release) that may be used to relax airway. Once it has been determined that the two ends of the airway will come together with minimal tension, attention is directed to the anastomosis. The anastomosis is performed with coated 4-0 Vicryl suture. The use of absorbable suture material avoids the possibility of suture-line granuloma formation, something that was seen with the use of nonabsorbable suture. All sutures are placed individually in a circumferential manner, beginning posteriorly and working anteriorly, first on one side and then on the other. The sutures are placed approximately 4 mm apart and approximately 3 mm from the edge of the cut airway. Anterolaterally, the sutures are placed through cartilage. All sutures are sequentially and carefully clipped to the drapes to ensure that they will not become entangled or the order confused.

After all of the sutures have been placed, the flexible endotracheal tube is removed, and the orotracheal tube is advanced into the distal airway. The lateral traction sutures are pulled together and tied with care to avoid intussusception. The anastomotic sutures are tied sequentially from front to back on each side, with each suture cut after it is tied. Once the anastomosis is completed, saline is instilled into the field, and the anastomosis is tested. All anastomoses are covered with pedicled viable tissue (e.g., strap muscle over trachea), and drains are placed at the site of the anastomosis. With tracheal resection and reconstruction, a suture is placed between the chin and sternum to maintain neck flexion postoperatively and to avoid extension and tension on the anastomosis. Except in rare circumstances, the patient is extubated in the OR.

Postoperatively, patients are monitored for any evidence of airway difficulties. A liquid diet is begun on the first postoperative day and advanced slowly. Close attention is paid to any evidence of anastomotic dehiscence (e.g., wound erythema or crepitus). All patients undergo bronchoscopic examination 1 week after surgery. If proper anastomotic healing is documented, the neck suture is cut, and the patient is discharged.

EDITOR'S COMMENT

Management of the airway in patients with suspected obstruction requires careful attention to detail. I have developed the following algorithm to improve safety. The OR staff is completely set up and immediately available. The patient receives topical anesthesia and remains awake while a laryngeal mask airway is applied. Flexible bronchoscopy then is carried out with local and minimal intravenous sedation, allowing the patient to maintain breathing control. Based on the bronchoscopic findings, the decision is made to back out or proceed with either general anesthesia, intubation with endotracheal tube, or rigid bronchoscopes. Concerning the tracheal resection, when extension of the cervical approach is required, I divide the manubrium and then T it off to the left in the second anterior costal interspace by placing a small sternal Tuffier spreader (Medicon Instrumente eG, Tuttlingen, Germany) without cutting the internal mammary artery. This exposure permits control of the innominate vessels and the midtrachea. This approach is also very effective for resection of substernal goiter.

–RB

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