The need for tracheal resection and reconstruction arises with airway obstructions (<5 mm luminal diameter) secondary to postintubation stenosis, with trauma, occasionally with short segment tracheomalacia, as well as with primary or secondary benign or malignant tumors. Most commonly, however, the pathology is of a benign nature. Lack of a suitable prosthetic or biologic replacement for the trachea limits the length that can be resected while avoiding undue tension on the anastomosis (maximum resection length 5 cm or 50% of the length in younger flexible patients without calcification). For this reason, the initial operation must be well planned and executed. Anastomotic dehiscence and other late complications of an unsuccessful first operation are difficult to fix in light of the limited material the surgeon has to effect a repair.
PRESENTATION OF BENIGN DISEASE
Patients usually present with shortness of breath, which initially occurs only on exertion but in more advanced cases 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 or previous intubations, as well as previously diagnosed malignancies, especially of the head and neck. Patients who present acutely with symptoms of stridor should be stabilized first by establishing a clear airway. 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. In fact, resection and repair are often delayed to permit adequate time for radiologic and diagnostic studies to aid in surgical planning. Emergency tracheal resection is rarely warranted. 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. 59-1A–C), with three-dimensional reconstruction, if possible (Fig. 59-2). 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.