TRACHEOBRINCHIAL RECONSTRUCTION

PRESENTED BY

ASHRAF HELALPROFESSOR OF CARDIOTHORCIC SURGERY, FACULTY OF MEDICINE, CAIRO UNIVERSITY.

INTRODUCTION

History of tracheal reconstruction:.Tracheostomy, performed in ancient times,

is the earliest attempt at tracheal surgery. Asclepiades (124-40 BC) have performed the first tracheostomy

.Ambroise Pare was the first to attempt repair of the trachea in the 16th century.

INTRODUCTION

.Throught the years, various attempts of tracheal resection and tracheoplasty have failed due to inadequate anaesthesia,limited knowledge of the tracheal anatomy and techniques of proper mobilization and repair of tracheobronchial tree.

.Mid 1960s,Grillo established the techniques of traceobronchial reconstruction

ETIOLOGY

Tracheal lesions can be either : .Congenital .Traumatic .Iatrogenic .Neoplastic

Tracheal stenosis with iatrogenic etiology

Tracheal stenosis with traumatic etiology

Tracheal stenosis with neoplastic lesions

Symptoms and Signs

.Shortness of breath generally described as progressive and exacerbated by exertion was the preponderant

symptom. Cough. Dysphagia. . Refractory asthma.

. Stridor was the preponderant sign, some with major airwayobstruction.. Hemoptysis . Recurrent pneumonia . Neck mass and airway compromise.

Investigations

.Chest roentgenograms may show evidence of narrowing of the tracheal air shadow.

.Computed tomography was excellent for showing the

extent of the lesion as well as the degree of stenosis.I t also accurately predicted involvement of contiguous cervical and mediastinal structures. In addition, it allowed us to rule out possible pulmonary metastases and other intrathoracic pathologic processes.

.Virtual bronchoscope: recent modality

.Rigid bronchoscopy was performed in all patients. It allowed accurate localization of the lesion and its extent and was also used to perform needle localization of the tumor for determining the site of the skin incision and the extent of resection.

.Barium swallow and esophagoscopy were performed if

esophageal involvement was suspected.

Anesthesia for tracheal surgery

. A small endotracheal tube was passed through the lesion if the stricture was successfully dilatable; otherwise, ventilation was maintained through an endotracheal tube situated above the stenotic area.

. If there was a prior tracheostomy, intubation was carried out through the stoma.

. Another sterile tubing set is available for use by the surgeon when performing the posterior raw of anastomosis .

. Extubation was accomplished in the operating room.

Surgical Management

. Surgical approaches:

.Cervical collar incision.

.Cervicomediastinal approach.

.Right thoracotomy.

.Median sternotomy

.Left thoracotomy.

Surgical Management

. Mobilization of the trachea has generally been performed prior to reconstruction by anterior and posterior dissection of the trachea followed by division of the inferior pulmonary ligament, pericardial release, suprahyoid release if required.

. The amount of trachea resected ranged from 2 to 6 cm. Up to 30% of the trachea can be safely resected and reanastomosed primarily. More extensive resection often leads to excessive tension and anastomotic failure

Surgical Management

. A variety of suture material was used for reconstruction as 3-0 Vicryl or 3-0

polydioxanone (PDS). . Reinforcement of the anastomosis with a

variety of autologous tissue as :.Strap muscles..Pleural flap. .Pericardial flap. .Pectoralis muscle flaps..Intercoastal muscle flap..Omentum.

Surgical Management

. The neck was immobilized by suturing the chin to the chest or a head and shoulder cast to maintain flexion. Immobilization ranged from 7 to 10 days.

. Tracheal stents may be used as an adjunct to reconstruction eg, Neville prosthesis and

Montgomery t tube.

Surgical Management

.Prosthetic reconstruction and replacement of the trachea :

.Marlex mesh.

.Pericardial flap reinforced with PTFE.

Complications of surgery

. Suture line dehiscence and mediastinitis.

. Stricture development.

. Atelectasis.

. Pneumonia, pulmonary edema.

. Perioperative pneumothorax

. Supraventricular arrhythmia.

. Hypothyroidism, hypoparathyroidism.

. Dysphagia and vocal cord paralysis.

Palliative Procedures

. Laser treatment of unresectable neoplastic

strictures may be beneficial as short-term palliation

. However, laser therapy prior to attempt resection and primary anastomosis is not indicated or necessary.

Laser Equipment

Dumon rigid laser bronchoscope with ventilating port, laser channel and suction channel.

Disposable large bore suction catheters.

Biopsy forceps with telescope.

Flexible bronchoscope. Endobrochial balloon

catheters in case of massive hemorrhage.

Laser Complications

. Failure to achieve an adequate airway

. Hemorrhage usually mild and represents only a nuisance.

. Asphyxia

. Tracheoesophageal fistula can occur in LMB or tracheal lesions.

. Mediastinal emphysema, pneumothorax.

. Delayed hemorrhage (probably results from necrosis of tumor that had invaded a nearby pulmonary artery)

. Endobronchial fire

. Eye injury to the patient or OR staff

Airway stenting

Inoperable, symptomatic lung cancer•  Primary airway tumours•  Oesophageal cancer•  Thyroid cancer•  Head and Neck tumours•  Metastases•  Postintubation and idiopatic benign tracheal stenosis•  Inflammatory lesions•  Tracheobronchial malacia•  Vascular compression

Tracheal obstruction dueto esophageal cancer

Renal cell ca in LMSbronchus

Lung cancer in RMSBronchus After stent placement

Stents complications. Complications seen with silicone stents

include .Migration of stent . Inspissation of thick mucous within the stent

lumen.

. Complications seen with metallic stents include:

. Growth of granulation tissue

. Uncovered metallic stents should not be inserted in patients with malignant airway lesions because the growth of cancer through the wire mesh negates the benefits of stent placement.

Lessons learned

. Patients with previous tracheal intubation and recent onset of ”asthma,”definitive evaluation by bronchoscopy is indicated

. Routine chest roentgenograms are not useful; tomography is excellent

. Bronchoscopy should be performed in all patients undergoing resection.

. Extensive resection may lead to excessive tension and anastomotic faliure.

. Post operative fixation of the neck for at least 7-10 days

. Cardiopulmonary bypass for resection of the trachea can be used. however, it is only in the occasional case that might need prosthetic reconstruction and replacement of the trachea.

.Palliative treatement of unresectable tumours may need laser therapy and or tracheal stent

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