Tracheal Resection - Clinical Tree

Introduction

Tracheal resection may be undertaken for tracheal strictures and tracheal tumors. Most commonly the trachea is exposed through a cervical incision, but for distal tracheal or carinal access either a sternotomy or a right thoracotomy may be required. Up to half the trachea may be resected with construction of a primary tracheal anastomosis. For the extensive resections, release techniques will be required. Preoperative planning is important to precisely define the tracheal lesion and always includes imaging and bronchoscopy.

Key Operative Points

1.
Preoperatively one must accurately assess the length and location of the lesion that is being resected.
2.
The tracheal resection must include all of the diseased airway so that the anastomosis can be done with healthy trachea.
3.
Neck flexion and release procedures should be done as required in order to minimize tension on the anastomosis.
4.
Circumferential mobilization of the airway should be minimized to maintain the circulation of the trachea.
5.
The recurrent laryngeal nerves are located in the trachea-esophageal groove and should be preserved to prevent vocal cord palsy.

Perioperative Period

History

1.
History of diabetes, previous external beam radiation, or steroid use, which can impair the healing of the trachea
2.
Previous tracheostomy or oral tracheal intubation and, if so, the duration of intubation
3.
History of Wegener disease or sarcoidosis, which can lead to tracheal stenosis
4.
A history of cigarette smoking
5.
Dyspnea and, if so, the duration and severity
6.
Cough

Physical Examination

1.
Overall body habitus
2.
Examination of the neck, including length, ability to extend the neck, and presence of kyphosis
3.
Cervical lymph adenopathy
4.
Audible stridor or wheezing

Imaging

Imaging is important to fully define the nature of the tracheal lesion for preoperative planning of the operation, with regard to location of the incision and the need for any tracheal release procedures.

1.
Chest and neck radiograph may show evidence of airway obstruction in the proximal trachea and would also detect gross mediastinal adenopathy or lesions in the lungs.
2.
Computed tomography (CT) scan is the most informative imaging study.
- a.
  It provides information regarding both the intraluminal and extraluminal extent of tracheal lesions.
- b.
  Evaluation of spread of tracheal cancers to the regional lymph nodes or the pulmonary parenchyma
- c.
  Allow for assessment of any other underlying pathology in the lung parenchyma.

Indications

1.
Airway intubation injury is the most common cause of tracheal strictures. It can occur from placement of oral endotracheal tubes or from previous tracheostomy. Most intubation injuries are relatively proximal and short and best managed with tracheal resection.
- a.
  Strictures that occur after tracheostomy may be located either at the site of the tracheal stoma or at the site of the cuff on the tracheostomy tube.
- b.
  Stenosis resulting from oral tracheal intubation usually follows a period of prolonged intubation for ventilator support. The level of injury can be the glottis, the subglottic segment, or the trachea.
2.
Idiopathic tracheal stenosis is a circumferential fibrotic lesion that involves the subglottic area as well as the proximal trachea.
3.
Tracheal tumors may be benign or malignant. In children, the majority of tumors are benign, whereas in adults, most are malignant.
- a.
  The most common benign tumors are carcinoid tumors and chondromas.
- b.
  The most common malignant tumors are squamous cell carcinoma and adenoid cystic carcinoma. Many malignant tracheal tumors are either locally advanced at presentation or have metastasized and as such are not treated with tracheal resection.

Contraindications

1.
The maximum length of trachea that can be resected with a primary anastomosis is 5 to 6 cm or roughly half the length of the trachea. Unless the surgeon is planning on a prosthetic tracheal replacement, longer lesions are not amenable to tracheal resection.
2.
Tracheal resection is generally not indicated in patients whose tracheal tumors have metastasized, although occasionally adenoid cystic metastases can progress extremely slowly and resection of an obstructing primary tracheal tumor may be appropriate.
3.
Patients need to be physiologically fit for surgery, although most patients can tolerate a transcervical operation well.
4.
Relative contraindications include:
- a.
  Diabetes
- b.
  Previous high-dose radiation to the trachea
- c.
  Current high-dose steroid use
- d.
  Active ongoing inflammation in the tracheal stricture

Preoperative Preparation

1.
An acutely inflamed tracheal stricture should not be operated on; the surgeon should wait until the inflammatory phase has resolved with treatment and the stricture has matured.
2.
Wean off of high-dose steroids prior to surgery.
3.
Pulmonary function tests can give an objective measure of the degree of airflow obstruction. Flow volume loops will demonstrate the degree of airflow obstruction during both the inspiratory and expiratory phase of respiration. Typically intrathoracic lesions cause obstruction of airflow during expiration, whereas lesions that are more proximal (or extrathoracic) will cause airflow obstruction during inspiration. With severe advanced, both inspiratory and expiratory airflow obstruction may be present.
4.
Bronchoscopy is used to accurately characterize the tracheal lesion prior to resection. That includes biopsy for histologic diagnosis of tracheal tumors. It also allows the surgeon to measure the longitudinal extent of tracheal lesions, document their precise location relative to the vocal cords and the carina, and evaluate the degree of obstruction of the airway. All of these factors are very important in establishing a patient treatment plan. In patients with severe airway obstruction and respiratory distress, endobronchial therapy via the bronchoscope can be used to relieve the obstruction and stabilize the patient until such time as definitive resection can be undertaken. That could include laser débridement or mechanical débridement of an endobronchial tumor or dilation of a benign stricture. Bronchoscopy is also useful to document vocal cord function prior to surgery.

Operative Period

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