Role of surgery for tracheal stenosis

and tumors

Paul De Leyn, MD, PhD

Chairman Department of Thoracic Surgery

University Hospitals Leuven

Belgium

C. Dooms, Department of pneumology

A. Neyrinck, Anesthesiology

M. Boada, Resident Thoracic Surgery

G. Deneffe †, Department of Thoracic surgery

Eindejaarsmeeting 4-6 december 2015

In memoriam Prof. G. Deneffe

• Chairman lung surgery

1994-2000

P. De Leyn, H. Decaluwé, D. Van Raemdonck,

C. Dooms, J. Yserbyt, G. Verleden, R. Vos

P. Delaere, V. Vanderpoorten

J. Vranckx

C. Deboeck, M. Proesmans

R. Hermans

Department of Thoracic Surgery

Department of Pneumology

Department of Otorhinology

Department of Plastic Surgery

Department of Pediatrics

Department of Radiology

Multidisciplinary Tracheal Workgroup

• Benign postintubation and tracheostomy

stenosis

– Surgical technique

– Literature results

– UZ Leuven results

• Idiopathic laryngotracheal stenosis

• Surgery for tracheal tumors

Anatomy

Tracheal resection with T-T anastomosis

Laryngotracheal resection with T-C

anastomosis

Technique - tracheotomy

Incision of trachea is made

at least 1-2 rings beyond

cricoïd !

Benign stenosis

• Bronchoscopy : length of stenosis.

Indication for surgery!!

• CT scan (sagittal plane) : distance from

posterior cricoid plate

• If stent : removal, bronchoscopy and CT

CT : easy tracheal stenosis

CT : tracheal stenosis up to cricoid

CT Reconstructions

Stent

CT : ossification after stent and laser (4 cm

resection)

Technique

• Experience of anesthesiologist!

• Endotracheal intubation

• Laryngeal mask is a good alternative

• IV anesthesia (since several periods of

apnea for performing )anastomosis

Classical laryngeal mask

LMA supreme (with suction port)

Incision : benign stenosis

• Cervicotomie

• + Manubrial split

• + Sternotomie

Anatomy

Benign Tracheal stenosis

Benign Tracheal stenosis

• Dissection on trachea

• Bipolar coagulation

• No repair of recurrent

nerve

• Peroperative bronchoscopy

(needle) to locate distal

end of stenosis

Cross field ventilation

Cross field ventilation

Anastomosis

• Intermittent apnea

• Posterior side : runnig

PDS 4/0

• Anterior side :

interrupted PDS 3/0

• Head in flexion.

Guardian stich when

indicated

Laryngotracheal resection

Laryngotracheal resection

Benign tracheal and laryngotracheal

stenosis : surgical treatment and results

• Retrospective series 65 patients

• Cervical approach in 60, cervical split 4, sternotomy : 1

• 70% tracheal resections and 30% laryngotracheal

resections

Rea et al, Europ J Cardiothorac Surg 2002

Benign tracheal and laryngotracheal

stenosis : surgical treatment and results

• Postoperative mortality : 1(1,5%)

• Major complications : 8(12,3%)– Anastomotic dehiscence : 4

– Vocal cord paralysis : 2

– Deglutition problems : 1

– Restenosis : 1

• Minor complications : 15 (23%)– Temporary vocal cord dysfunction : 8

– Superficial wound infection 5

– Anastomotic granulation tissue 2

Rea et al, Europ J Cardiothorac Surg 2002

Predictors for postoperative complications

after tracheal resection

• Retrospective analysis 94 patients (patients with

idiopathic laryngotracheal resections were excluded

• Complications more common in laryngotracheal

resections and lenght of resection is important

Bibas et al, Ann Thorac Surg 2014

Idiopathic laryngotracheal stenosis

• Female patients (30-

50y)

• Idiopathic

• Wegener should be

excluded

Idiopathic laryngotracheal stenosis

• Female patients (30-

50y)

• Idiopathic

• Can be very close to

vocal cords

Idiopathic laryngotracheal stenosis

Removal of anterior part of cricoid

Removal of mucosa of posterior plate of cricoid (diamond drill)

Flap of pars membranacea to cover posterior plate of cricoid

Idiopathic laryngotracheal stenosis

Removal of anterior part of cricoid

Removal of mucosa of posterior plate of cricoid (Diamond drill)

Flap of pars membranacea to cover posterior plate of cricoid

Collaboration with ENT surgeon

Primary tumours of the

trachea

• Rare

• Epidemiological studies (USA,

Netherlands)

– Annual incidence 1-2%/miljon inhabitants

Primary tumours of the

trachea : pathology

• Malignant : 90%– Squamous cell carcinoma : 35% (50% in

epidemiological series)

– Adenoid Cystic carcinoma : 35%

– Carcinoids: 10%

– Lymphoma 3%

– Non-squamous cell carcinoma 3%

– Sarcoma 3%

• Benign : 10%

Primary tumours of the

trachea : diagnosis

• Bronchoscopy

• CT scan

• In some cases mediastinoscopy (just

before resection)

Tracheal surgery Leuven

1994 – april 2014

✦82 tracheal resections 1994-2015 Gender distribution 50%

Age 52,45 ± 18,48 years

Indications

• Stenosis: 60 cases (73,2%)

• Tumor: 15 cases (18,3%)

• Fistula: 5 cases (6,1%)

• Trauma: 2 cases (2,4%)

Tracheal resection for stenosis

• Postintubation: 50 cases

• Idiopathic: 9 cases

• Compression: 1 case

Tracheal resection for postintubation

stenosis (n=50)

• Age, 53,74 ± 16,8 years

• Length 3,04 ± 0,51 cm

• 12 complications (24%)

• 4 reoperation (one late)(8%)

• No postoperative death

Mean Range

Day of disharge

post-operative

(days)

9 4-39

Table 3. Post-operative hospital stay

Tracheal resection

for postintubation

stenosis (n=50)

POST-INTUBATION TRACHEAL STENOSIS

Characteristics

Age (mean) 53,74 +- 16,8

Gender (M:F) 26:24

Preoperative

Previous Tracheostomy 20 (40%)

Endotracheal treatment 34 (68%)

Dilatation 12 (24%)

Laser 21 (42%)

Stent 18 (36%)

Surgery

Length (cm) 3 +- 0,51

Technique

T-T 32 (64%)

T-C 12 (24%)

Pearson 6 (12%)

Postoperative

Complications 12 (24%)

Reoperation 4 (8%)

Postoperative mortality 0 (0%)

• 30 (60%) patients had previous tracheostomy

• 34 (68%) had previous endobronchial intervention

– Stent 21 (42%), Laser 18 (36%), Dilatation 12 (24%)

– Single 19 (38%), Double 13 (26%), Triple 2 (4%)

Tracheal resection for postintubation

stenosis (n=50)

Tracheal resection for postintubation

stenosis (n=50)Approach:

• 43 (86%) cervicotomy, 5 (10%) partial sternotomy, 2

(4%) sternotomy

Technique:

• 32 (64%) Tracheal-Tracheal

• 12 (24%) Tracheal-Cricoid

• 6 (12%) Pearson

T-T, 32 (64%) Pearson, 6 (12%)T-Cr 10 (20%)

Tracheal resection for postintubation

stenosis (n=50)

Tracheal resection for postintubation

stenosis (n=50)

12 patients had complications

24% of all surgeries

4 patients needed a reoperation

3 for tracheostomy (1 permanent)

1 Posterior plate enlargement (after 2 years)

No hospital mortality

Tracheal resection for postintubation stenosis

(n=50). Complications in 12 patients

• Tracheostomies : 3– subglottic stenosis 85 y

– laryngeal oedema (removed 6 weeks)

– anterior dehiscence (removed after 6 weeks)

• Dehiscence : 2– Tracheostomy

– No treatment : discharged d 10

• Reintubation : 2

Tracheal resection for postintubation stenosis

(n=50). Complications in 12 patients

• Stenosis : 2– Tracheostomy

– Posterior enlargement (after 2 years)

• Wound infection: 2

• ARDS : 1

• Pneumonia : 1

• Other (minor) : 2

Tracheal resection for tumor

• Primary tracheal tumor, 11

• Infiltration , 2

• Metastases, 1

• Recurrence, 1

Squamous, 2

Adenoid Cystic, 5

Sarcoma, 1

Leiomioma, 1

Carcinoid, 1

Clear cell, 1

Case clear cell carcinoma

• Male 21 y

• Hemoptoe

• Midtracheal nodular

lesion : clear cell

carcinoma

Case clear cell carcinoma

• Right thoracotomy

• Bronchoscopic

reperage

• 3 cm resektion.

Anastomosis +

intercostal muscle flap

• Complete resektion

• Discharged day 7

Right Thoracotomy (4th IC, Intercostal

muscle flap)

Recurrence adenoid cystic

carcinoma

Recurrence adenoid cystic carcinoma

• Female 72 y

• Stent en chemoradiotherapy

for adenoid cystic carcinoma 5

cm (6 years ago)

• Recurrence

• Right thoracotomy. Resection

4 cm of trachea + IC muscle

flap

• Distal margin microscopically

positive (advised

brachytherapy)

Bronchoscopy 7 days

Bronchoscopy 1 year

Conclusion

• Multidisciplinary approach!

• Tracheal surgery requires meticulous

surgical technique

• Good results with surgery for benign

stenosis

• Idiopathic laryngotracheal stenosis and

tracheal tumors : rare and complex

disease