Background
Tracheal resection with primary reanastomosis for tracheal tumors and stenosis is a well-described procedure. [1, 2, 3, 4] It is most commonly indicated for postintubation lesions but is also performed for malignancies, secondary tracheal tumors, and tracheoesophageal and tracheal innominate fistulas. Approximately half of the trachea can be safely removed with a low incidence of anastomotic complications. [2, 3, 4, 5]
Because of the lack of suitable replacement material for the trachea, various mobilization and release maneuvers have been demonstrated to increase the length of the tracheal resection by elevating the carina. These include hilar, suprahyoid, and suprathyroid laryngeal release [2, 6, 7] ; anterior and posterior digital tracheal dissection; and constant neck flexion. Research into the use of bioprosthetic materials for tracheal replacement is ongoing. [8]
Constant neck flexion by a suture between the skin of the point of the chin and midline of the chest over the manubrium has been widely considered paramount for successful tracheal resections. An orthosis has also been used as a more comfortable alternative to utilizing the traditional suture between the chin and the midline of the chest over the manubrium. [9] The use of tracheal retention sutures on the proximal and distal-lateral edges of the anastomotic line has also been suggested as an alternative to the traditional chin suture for reducing tension on the anastomosis. [10]
Thoracoscopic and robotic-assisted tracheal resections, though not as common at present, have also been described. [11, 12]
Indications
Postintubation lesions are the most common indication for tracheal resection and reconstruction. Malignancies (including, predominantly, squamous cell carcinoma and adenocystic carcinoma) also remain an indication for resection. [13, 14] Other indications include secondary tracheal tumors and tracheoesophageal and tracheal innominate fistulas. [15] (See the images below.)
This resected tracheal segment shows internal and external changes that were secondary to prolonged endotracheal intubation.
This photo shows a resected tracheal segment (same segment as in the previous image).
This resected tracheal segment shows ulceration of the mucosa and cartilage, granulation tissue, and fibrous tissue.
Contraindications
Contraindications for tracheal resection and reconstruction include the following:
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Medical contraindications for such extensive surgery
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Impaired pulmonary function - A careful evaluation of pulmonary function, if lung resection is to be included, is mandatory and should include spirometry and possibly quantitative ventilation-perfusion scans
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Problematic anatomy - For a right carinal pneumonectomy (the most common carinal resection), the distance from the right distal tracheal margin to the proximal medial left mainstem should not exceed 4 cm in most cases; resections that exceed this are likely to result in excessive anastomotic tension
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Prior irradiation - This is a relative contraindication and should be accompanied by some type of flap, including pleural, intercostal muscle, or omental wrapping [16]
Technical Considerations
Anatomy
The trachea is nearly but not quite cylindrical and is flattened posteriorly. In cross-section, it is D-shaped, with incomplete cartilaginous rings anteriorly and laterally, and a straight membranous wall posteriorly. The trachea measures about 11 cm in length and is chondromembranous. This structure starts from the inferior part of the larynx (cricoid cartilage) in the neck, opposite C6, and extends to the intervertebral disk between T4 and T5 in the thorax, where it divides at the carina into the right and left bronchi.
For more information about the relevant anatomy, see Trachea Anatomy.
Outcomes
Johnson et al analyzed 2014-2016 data from the American College of Surgeons (ACS) National Surgical Quality Improvement Program (NSQIP) to determine perioperative outcomes for 126 patients who underwent tracheal resection or tracheoplasty. [17] Such outcomes included length of stay (LOS), dehiscence, unplanned reintubations, unplanned surgeries, and 30-day readmission rates. The median LOS was 7 days. Six patients (4.8%) developed wound infections, and three (2.4%) developed wound dehiscence. Five (4.0%) required unplanned reintubation, and 16 (13%) had an unplanned reoperation. The 30-day unplanned readmission rate was 16% (20/126).
In a systematic review of 37 studies that included 656 patients with locally advanced thyroid cancer treated by means of (crico-)tracheal resection with primary anastomosis ([C]TRA), Piazza et al found a 2.0% risk of perioperative mortality and a 27.0% surgical complication rate. [18] A permanent tracheotomy was required in 4.0% of patients. Oncologic outcomes varied, with 5-year overall survival rates of 61-100%, 10-year overall survival rates of 42.1-78.1%, 5-year disease-specific survival rates of 75.8-90%, and 10-year disease-specific survival rates of 54.5-62.9%.
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This resected tracheal segment shows ulceration of the mucosa and cartilage, granulation tissue, and fibrous tissue.
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This resected tracheal segment shows internal and external changes that were secondary to prolonged endotracheal intubation.
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This photo shows a resected tracheal segment (same segment as in the previous image).
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Tracheal resection part 1a. Video courtesy of Dr Mueller.
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Tracheal resection part 1b. Video courtesy of Dr. Mueller
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Tracheal resection part 1c. Video courtesy of Dr. Mueller
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Tracheal resection part d. Video courtesy of Dr. Mueller
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Tracheal resection part 2a. Video courtesy of Dr. Mueller
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Tracheal resection part 2b. Video courtesy of Dr. Mueller
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Tracheal resection part 2c. Video courtesy of Dr. Mueller
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Tracheal resection part 2d. Video courtesy of Dr. Mueller
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Tracheal resection part 3a. Video courtesy of Dr. Mueller
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Tracheal resection part 3b. Video courtesy of Dr. Mueller
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Tracheal resection part 3c. Video courtesy of Dr. Mueller
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Tracheal resection part 3d. Video courtesy of Dr. Mueller
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Tracheal resection part 4a. Video courtesy of Dr. Mueller
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Tracheal resection part 4b. Video courtesy of Dr. Mueller
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Tracheal resection part 4c. Video courtesy of Dr. Mueller
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Tracheal resection part 4d. Video courtesy of Dr. Mueller
