Tracheal resection is performed most commonly for benign disorders. The primary indication is fibrotic stenosis, whether idiopathic, traumatic, or postintubation. Occasionally, tracheal resection is indicated for neoplastic disease or short-segment malacia.
Patients usually present with shortness of breath, which occurs initially only on exertion but in more advanced cases it may even occur at rest. There is often a history of treatment with numerous bronchodilators or steroids for presumed asthma. Occasionally, previous endotracheal intubation or tracheostomy has prompted imaging studies and an earlier referral to a thoracic surgeon. It is important in the history to delve into any previous airway interventions, such as tracheostomy, previous intubations, as well as previously diagnosed malignancies, especially of the head and neck. On examination, patients generally are comfortable at rest but manifest stridor, which usually is inspiratory in nature but occasionally expiratory. Even with severe tracheal stenosis, patients still may have acceptable oxygen saturation. Symptoms usually do not manifest until there is quite a significant degree of stenosis, on the order of a residual 5-mm lumen.
Imaging is a necessary part of the preoperative preparation. Except for patients with acute airway compromise, imaging studies always can be done before the endoscopic assessment or operative intervention. Detailed CT scans of the neck and chest are performed routinely (Fig. 57-1), with three-dimensional reconstruction, if possible (Fig. 57-2). These studies aid in planning for airway management and endoscopic assessment and warn of possible surprises, such as severe distal tracheal or bilateral proximal bronchial stenoses, which may not show on x-rays.
CT scans of tracheal separation. A. Level above separation. B. Level of stenosis. C. Level just below separation.
Three-dimensional reconstruction of tracheal separation. Tracheostomy tube inserted into distal lumen.
Except for the extremely fragile patient, most will be able to tolerate a tracheal resection if it does not require a thoracotomy. The endoscopic assessment therefore is pursued with a possible resection foremost in mind. This evaluation should be performed independent of surgery because repeat dilations of cicatricial stenoses can delay or obviate the need for surgery altogether.
The bronchoscopy should be conducted in the operating theater, with both flexible and rigid bronchoscopes of varying sizes available, as well as dilators and equipment for tracheostomy or tracheal-tube (T-tube) insertion. The questions to be answered include:
Should this lesion be managed by resection or by more conservative means?
Is the lesion amenable to a tracheal resection?
What surgical approach will be needed for the level and length of this lesion?
Can we proceed safely with surgery, or should we allow some time ...
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