Adult Chest Surgery

Chapter 54. Techniques of Tracheal Resection 

The need for tracheal resection and reconstruction arises with airway obstruction (<5 mm luminal diameter) secondary to postintubation stenosis, primary or secondary benign or malignant tumors, or trauma. Patients who present acutely with symptoms of stridor should be stabilized first by establishing a clear airway. Resection and repair are often delayed to permit adequate time for radiologic and diagnostic studies to aid in surgical planning. Emergency tracheal resection is rarely warranted. Lack of a suitable prosthetic replacement for the trachea limits the amount of this organ that can be resected without placing undue tension on the anastomosis (maximum resection length 5 cm). For this reason, the initial operation must be well planned and executed. Anastomotic dehiscence and other late complications of an unsuccessful first operation are difficult to reverse given the limited material the surgeon has to effect a repair.

GENERAL SURGICAL PRINCIPLES

The surgical approach to an upper airway tumor depends on its location. Proximal tracheal lesions require resection of the trachea and possibly the cricoid cartilage or larynx. Segmental resection of the trachea with direct end-to-end anastomosis is used to remove tracheal main body lesions. Removal of tumors that involve the distal trachea, carina, or main stem bronchus requires some form of carinal resection, with the extent of airway resection determining the mode of reconstruction. If the disease process involves the lobar orifices, resection can be accomplished by including contiguous resection of the affected lobes.1,2 Lymph nodes should be resected whenever possible for staging, although extended lymphadenectomy can devascularize remaining airway tissue and should be avoided.

Preoperatively, patients should stop smoking and be weaned from steroids 2–4 weeks before resection to avoid deleterious effects on anastomotic healing.1 Bronchoscopic techniques can be used, if needed, for temporary palliation for patients with severe obstruction while surgery is delayed. The anesthesiologist should place an epidural catheter preoperatively and have experience with complex airway management. Anesthetic management should include inhalation induction and short-acting medications to permit early extubation, which will decrease pressure on the airway anastomosis. For carinal resections, mediastinoscopy should be performed at the time of resection both for staging and to develop the pretracheal plane to improve mobility of the upper airway and lessen the chance of subsequent injury to the left recurrent laryngeal nerve when the distal trachea is dissected free at thoracotomy.1 Ventilation during airway resection is achieved by distal airway intubation with an armored-type endotracheal tube connected to sterile anesthesia tubing across the surgical field. A sterile camera bag also can be used to house the airway tubing that is passed across the surgical field. The endotracheal tube is pulled back into the proximal airway by the anesthesiologist before airway incision.

After the distal resection margin is incised and the airway is divided circumferentially, the distal airway is intubated by the surgeon while the anesthesia team switches to the sterile circuit. If necessary, both lungs can be ventilated separately for carinal resections.3 Either a double-lumen endotracheal tube or a long single-lumen tube with selective intubation of the contralateral main stem bronchus or a bronchial blocker positioned in the ipsilateral bronchus can be employed for main stem bronchi resections.4 If necessary, the ipsilateral lung can be ventilated across the operative field if single-lung mobilization is poorly tolerated. The size and inflexibility of double-lumen tubes can present difficulties in procedures that involve carinal resection, and the extralong single-lumen tube advanced into a main stem bronchus to provide single-lung ventilation is preferable.1 The remaining main stem bronchus is intubated across the operative field as resection proceeds.1 For carinal resections, the original long endotracheal tube is advanced into the bronchus after the end-to-end tracheobronchial anastomosis is brought together, permitting uninterrupted ventilation during completion of the secondary anastomosis of the remaining bronchus to the trachea.

A great deal of teamwork between the surgeon and the anesthesiologist is required during these cases. Completing tracheal anastomoses will require removing and replacing the endotracheal tube, during which time the anesthesiologist will need to hold ventilation and also be responsible for keeping the surgeon apprised of the patient's status and the estimated timing for reinstituting ventilation. This cycle is repeated until the distal airway is reintubated.

A red rubber catheter can be sutured to the tip of the original endotracheal tube for upper tracheal tumors in cases where withdrawal of the tube proximal to the anastomosis will result in extubation. The profile and hindrance to reconstruction of the red rubber catheter can be further reduced by passing a heavy suture through the tip, which then can be used as a "leader" to guide the tube back through the vocal cords for reintubation of the distal airway from above.

Complete resection at the time of the first operation is the goal to relieve airway obstruction and give the best chance for cure. Since the margins can extend beyond what is grossly visualized and palpable, especially with adenoid cystic carcinoma, intraoperative frozen sections of resection margins are very important. However, upper airway tumor resection involves a compromise between the need to obtain clear margins to prevent postoperative recurrence and preservation of airway length to reduce anastomotic tension and ensure adequate healing. The safe limits of tracheal resection often depend on sound clinical judgment and vary with age, neck mobility, and body weight. Thin patients with long necks generally can tolerate longer lengths of tracheal resection, as can younger patients because of greater tracheal elasticity. Less than complete tumor resection may be acceptable to provide a long period of symptom-free palliation if morbidity risks limit the operative choice, especially for radiosensitive tumors such as adenoid cystic carcinoma.5,6

Various techniques have been described for airway anastomosis. Absorbable sutures are used for all airway anastomoses to minimize the potential for granuloma formation. Either silk or Vicryl lateral traction sutures should be placed through the cartilaginous rings on the remaining proximal and distal airway segments as "traction sutures" to take tension off the suture lines when the sutures are tied. Our preferred technique is to use interrupted sutures of 4-0 Vicryl placed in the trachea, with the posterior membranous airway knots placed interiorly (Fig. 54-1A) and the anterior cartilaginous airway knots placed on the outside7 (Fig. 54-1B). It should be noted that the preferred technique at the Massachusetts General Hospital, where many of the airway surgery procedures were developed, is to use interrupted 4-0 Vicryl sutures, with all knots placed on the outside1 (Fig. 54-2). Other anastomoses with running sutures or a combination of running and interrupted sutures have been reported. In all likelihood, a successful anastomosis can be constructed if these central tenets are observed: preservation of airway vascular supply, tension-free apposition of the ends (perhaps secondary to the use of proximally and distally placed traction sutures and the appropriate release maneuvers), and accurate tissue approximation with absorbable sutures.

Figure 54-1.

 

Preferred method for anastomotic suture at our institution is to use interrupted sutures of absorbable 4-0 Vicryl (A) with the posterior membranous airway knots placed interiorly and (B) the anterior cartilaginous airway knots placed exteriorly.

 

Figure 54-2.

 

Approach used at the Massachusetts General Hospital, with interrupted 4-0 Vicryl sutures, all placed exteriorly.

 

Almost half the trachea can be removed with a low-tension primary anastomosis when appropriate mobilization techniques are employed. Simple neck flexion may be the most useful single maneuver for reducing anastomotic tension. Dissection of the anterior avascular pretracheal tissue planes while preserving the blood supply in the lateral tissue pedicles, which can be performed via mediastinoscopy, permits some tracheal mobilization, especially distally. Because the tracheal blood supply is segmental, skeletonization of the proximal and distal tracheal ends should be performed for only approximately one tracheal ring, the extent needed to perform the anastomosis. Because extensive lymph node dissection can compromise the trachea and, ultimately, the anastomotic blood supply, it should be avoided. Additional methods can be used if the anastomosis appears to have excessive tension. Suprahyoid laryngeal release by separating the larynx from its thyrohyoid attachments is useful for achieving proximal tracheal mobility for resections that involve the proximal or midtrachea (Fig. 54-3). Postoperative aspiration precautions are needed after laryngeal release because some patients may have initial swallowing difficulties.5 The distal trachea can be mobilized by inferior pulmonary ligament division and mobilization of the right main stem bronchus from the pericardium and the right main pulmonary artery and right superior pulmonary vein. The left main stem bronchus may be divided and reanastomosed end to side with the right main stem bronchus or bronchus intermedius to provide further mobility. Postoperatively, a heavy suture should be placed loosely from the inferior chin to the anterior chest wall and kept in place for 1 week to prevent inadvertent patient neck extension.1,7

Figure 54-3.

 

A. Suprahyoid laryngeal release is performed by separating the larynx from its thyrohyoid attachments to create proximal tracheal mobility for resections of the proximal or midtrachea. B. Appearance of trachea after laryngeal release.

SURGICAL TECHNIQUE

Approach to Upper and Middle Tracheal Neoplasms

A cervical approach is used for tumors of the upper third of the trachea.7,8 The patient's neck and anterior chest are prepared and draped after the patient is placed in the supine position with the neck maximally extended by an inflatable bag behind the shoulders. Neck extension delivers the trachea into the neck. A collar incision is made with platysmal flaps developed to the level of the hyoid bone superiorly and the sternal notch inferiorly. The incision can be extended by making an additional skin incision perpendicular to the collar incision to include a partial or complete median sternotomy if necessary for midtracheal lesions. The strap muscles are separated in the midline, and the dissection is continued to the trachea in the midline. The trachea is mobilized circumferentially at the inferior resection margin, with care taken to avoid injury to the recurrent laryngeal nerves bilaterally and excessive circumferential mobilization that could compromise blood supply to the unresected trachea. The anterior aspect of the trachea is mobilized well into the mediastinum. This is easily accomplished in a virgin mediastinum with digital dissection. The endotracheal tube is pulled back into the proximal trachea by the anesthesiologist. After the distal resection margin is incised and the trachea is divided circumferentially, the sterile armored endotracheal tube is placed into the distal airway. The superior aspect of the divided trachea is grasped with a clamp, and the segment to be resected is mobilized to the level of the proximal resection margin and then removed (Fig. 54-4). A partial laryngeal resection may be required if portions of the cricoid cartilage need to be resected to obtain clear margins, with the trachea tailored to fix the irregular proximal defect.8 Care should be taken to preserve the recurrent laryngeal nerves, if at all possible. A permanent cervical tracheostomy is performed in patients who require resection of both the trachea and the entire larynx.5

Figure 54-4.

 

A. Proximal and distal incision points for the tracheal resection. B. Note the sterile armored endotracheal tube, which has been placed into the distal airway after the distal margin has been excised. C. The superior aspect of the divided trachea is grasped with a clamp, and the segment to be resected is mobilized to the level of the proximal resection margin and then removed.

The tracheal anastomotic sutures are placed as described earlier. The neck is taken out of extension and flexed with the support of a pillow. The silk stay sutures are pulled toward each other to relieve tension, and the tracheal sutures are tied, starting posteriorly. In addition to the standard anterior tracheal mobilization technique, a suprahyoid release is performed if the suture line appears to be under any tension. The endotracheal tube is advanced and positioned distal to the anastomosis. After closure of the incision, the chin stitch described earlier is placed and kept for 1 week to avoid inadvertent patient neck extension.

Approach to Lower Trachea, Carina, and Main Stem Bronchial Neoplasms

Several approaches can be used for lower airway tumor excision. Tumors of the middle or lower trachea can be removed with either a right posterolateral thoracotomy, entering through the fourth or fifth intercostal space, or a median sternotomy.5,8 An ipsilateral posterolateral thoracotomy can be used for lesions that involve the main stem bronchi but not the carina.4 A bilateral anterior thoracosternotomy (clamshell) incision that gives access to both pleural spaces may be preferable in selected patients, especially those involving a left carinal pneumonectomy.1 The carina or main stem bronchus is resected after mobilization of the distal trachea and main stem bronchi, with ventilation achieved as described earlier.

The mode of subsequent airway reconstruction depends on the relative extent of tracheal and bilateral main stem bronchi resection.1 When the lesion is confined solely to a main stem bronchus, a main stem bronchial sleeve can be resected with primary anastomosis (Fig. 54-5A). A neocarina can be formed for carinal resections that involve a limited amount of tracheal resection by reapproximation of the right and left main stem bronchi (Fig. 54-5B). Most of the airway mobilization in this reconstruction comes from the trachea because the aortic arch limits cephalad movement of the newly formed carina, and therefore, this reconstruction is not appropriate when a more extensive amount of trachea is resected. If a moderate amount of trachea is resected, the trachea is anastomosed end to end with either the right or left (preferred) main stem bronchus, with the contralateral bronchus reimplanted into the side of the trachea (Fig. 54-5C). As a general guideline, the extent of airway resection should be limited to less than 4 cm to minimize the risk of anastomotic complication owing to the relative immobility of the left main stem bronchus when the airway reconstruction involves anastomosis of the left main stem bronchus to the trachea.1 If an extensive amount of trachea is resected, the right main stem bronchus is anastomosed end to end to the trachea, with the left bronchus reimplanted into the bronchus intermedius. The reverse reconstruction (left main stem end to end to the trachea with the right bronchus reimplanted into the left main stem bronchus) should be approached with great caution because the immobility of the left main stem bronchus leads to a significant incidence of anastomotic complications when there is extensive airway resection.

Figure 54-5.

 

A. For lesions confined solely to a main stem bronchus, a main stem bronchial sleeve can be resected with primary anastomosis. B. A neocarina can be created for carinal resections that involve a limited amount of tracheal resection simply by reapproximating of the right and left main stem bronchi. C. For moderate tracheal resection, the trachea is anastomosed end to end with either the right or left (preferred) main stem bronchus while the contralateral bronchus is reimplanted into the side of the trachea. D-H. Other variations.

 

When the lesion involves the orifice of the right upper lobe, a right upper lobe sleeve resection can be performed, with the bronchus intermedius reimplanted to either side of the trachea or the left main stem bronchus if anastomotic tension is thought to be prohibitive.1,2 When resection includes both the right upper and middle lobes, the right lower lobe bronchus should be reimplanted into the left main stem bronchus. If there is either extensive endobronchial involvement, destroyed lung as a result of bronchial obstruction, or involvement of the ipsilateral hilar vessels, a carinal sleeve pneumonectomy with end-to-end anastomosis of the trachea to the remaining main stem bronchus can be performed.

The end-to-end tracheal-bronchial anastomotic sutures then are placed as described earlier after both margins are examined histologically. The indwelling endotracheal tube is advanced into the bronchus beyond the anastomosis after placement of all sutures. First the traction and then the anastomotic sutures are secured. The anastomosis is tested for air leaks and repaired as needed. The end-to-side anastomosis then is constructed, with the opening created in the side of the trachea or bronchus entirely in the cartilaginous wall to provide rigidity to the anastomosis and at least a centimeter away from the end-to-end anastomosis to avoid devascularization and necrosis of the intervening cartilaginous tissue1 (Fig. 54-6). All suture lines should be reinforced with circumferential vascularized flaps of pleura, pericardium, omentum, or serratus anterior or intercostal muscle, especially if there is a history of mediastinal irradiation.9

Figure 54-6.

 

An opening is created in the side of the trachea or bronchus for the end-to-side anastomosis. The opening is entirely in the cartilaginous tissue at least 1 cm away from the end-to-end anastomosis to avoid devascularization and necrosis of the intervening cartilaginous tissue.

POSTOPERATIVE MANAGEMENT

Postoperatively, early ambulation, incentive spirometry, chest physical therapy, and bronchoscopy, as necessary, should be used to help patients clear secretions. Bronchoscopic guidance should be used if reintubation is required in the early postoperative period to avoid lifting the larynx. Postoperative radiation should be used for virtually all malignant lesions, except very superficial tumors.8 Local control with postoperative radiation is excellent for adenoid cystic carcinoma in particular, making grossly clear but microscopically positive margins acceptable, if necessary. Serial follow-up examinations for benign lesions are recommended, especially when tracheal resection is not performed. Follow-up examination similar to that for lung cancer is appropriate for malignant lesions. Patients who undergo resection of adenoid cystic carcinoma should have extended long-term follow-up, possibly with annual bronchoscopy, because these lesions have been found to recur as long as 17 years after initial resection.8,10

POSTOPERATIVE COMPLICATIONS

Operative mortality generally depends on both the physiologic impact of the procedure and the length of the airway resection and has improved dramatically over time as surgical judgment and techniques have been refined. Overall operative mortality is 5–10% and is expected to be lowest in centers where tracheal surgery is performed commonly.3,8,11 Operative mortality after tracheal resection has been reported to be as low as 1%, with a 12–15% mortality after carinal resection.8,12 Predominant predictors of operative death after carinal resection include postoperative mechanical ventilation, length of resected airway, and development of anastomotic complications.1 Anastomotic complications have been observed in 17% of patients undergoing carinal resection and almost always result in death or require surgical reintervention.1 Early anastomotic complications include necrosis. Late anastomotic complications include stenosis and formation of excessive granulation tissue. Other relatively common complications after resection include atrial arrhythmias and pneumonia.

SUMMARY

Malignant tumors of the trachea are rare and often silent for many years. Delayed diagnosis, coupled with a lack of symptoms distinguishable from other more common pulmonary disorders, often means that by the time of detection, the tumor has spread longitudinally beyond the recommended limits of tracheal resection (5 cm or less). The procedure is demanding in terms of surgical planning and execution, and other than tertiary referral centers, few centers treat sufficient numbers of patients to accrue the experience needed for the safe performance of this surgery.

EDITOR'S COMMENT

Carinal resection for cancer is a high-risk operation and should not be performed by surgeons without previous experience. It is particularly important for the anesthesiologists and intensivists to avoid overhydration and overexpansion of the remaining lung to prevent post-pneumonectomy complications.

–RB

REFERENCES

1. Mitchell JD, Mathisen DJ, Wright CD, et al: Clinical experience with carinal resection. J Thorac Cardiovasc Surg 117:39, 1999.[PubMed: 9869757]

2. Chen F, Tatsumi A, Miyamoto Y: Successful treatment of mucoepidermoid carcinoma of the carina. Ann Thorac Surg 71:366, 2001.[PubMed: 11216788]

3. Maziak DE, Todd TR, Keshavjee SH, et al: Adenoid cystic carcinoma of the airway: Thirty-two-year experience. J Thorac Cardiovasc Surg 112:1522, 1996.[PubMed: 8975844]

4. Cerfolio RJ, Deschamps C, Allen MS, et al: Main stem bronchial sleeve resection with pulmonary preservation. Ann Thorac Surg 61:1458, 1996.[PubMed: 8633959]

5. Pearson FG, Todd TR, Cooper JD: Experience with primary neoplasms of the trachea and carina. J Thorac Cardiovasc Surg 88:511, 1984.[PubMed: 6090818]

6. Refaely Y, Weissberg D: Surgical management of tracheal tumors. Ann Thorac Surg 64:1429, 1997.[PubMed: 9386715]

7. Kaiser L: Tracheal Resection. In Kaiser LR (ed). Atlas of General Thoracic Surgery. St Louis, Mosby Yearbook, 1997.

8. Grillo HC, Mathisen DJ: Primary tracheal tumors: Treatment and results. Ann Thorac Surg 49:69, 1990.[PubMed: 2153371]

9. Muehrcke DD, Grillo HC, Mathisen DJ: Reconstructive airway operation after irradiation. Ann Thorac Surg 59:14, 1995.[PubMed: 7818313]

10. Allen MS: Malignant tracheal tumors. Mayo Clin Proc 68:680, 1993.[PubMed: 8394484]

11. Gaissert HA, Grillo HC, Shadmehr MB, et al: Long-term survival after resection of primary adenoid cystic and squamous cell carcinoma of the trachea and carina. Ann Thorac Surg 78:1889, 2004.[PubMed: 15560996]

12. Mitchell JD, Mathisen DJ, Wright CD, et al: Resection for bronchogenic carcinoma involving the carina: Long-term results and effect of nodal status on outcome. J Thorac Cardiovasc Surg 121:465, 2001.[PubMed: 11241081]



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