Whether to undergo tracheal resection or balloon dilation in the setting of tracheal stenosis is a controversial and difficult thing to assess. Both procedures are indicated in stenosis and have varying success rates. Balloon dilation is minimally invasive but has many limiting factors for success such as scarring, severe stenosis, or cartilage support. Tracheal resection is much more complicated and comes with higher risk of complications but can be done in virtually any patient with obstruction or tracheal stenosis. The selection of which procedure is largely dependent on the condition of the patient, the location and length of the stenosis, and surgeon preference. Therefore, it is interesting to examine both techniques in the setting of a patient with severe tracheal stenosis to see which procedure would result in the best outcome.
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Tracheal resection and balloon dilation are options for patients with tracheal stenosis. Care must be taken to ensure the right procedure is selected for the given patient. Mr. PL presented to clinic in June with a long history of subglottic stenosis and a tracheo-esophageal fistula. His social history is significant for excessive tobacco use and alcohol consumption, and his medical history for chronic pain, hypertension, ADHD, and anxiety. Mr. PL is currently taking Adderall for his ADHD and hydrocodone for chronic pain management. He experienced subglottic/tracheal stenosis secondary to intubation after overdosing in early 2018. A CT was performed, and 2-2.5 cm of upper tracheal stenosis was found. He had a tracheostomy and PEG tube placed at that time.
He was last seen in clinic February of 2019 with a tracheal resection planned for the future at that time. Due to the patient’s history of ADHD and anxiety, hewoke up very combatant after he was placed under anesthesia for his tracheostomy tube placement. This, combined with his smoking and drinking status, suggested to Dr. Greene that he would no longer be a good candidate for tracheal resection. He was then advised to come to clinic once a month for nicotine testing to prove that he was no longer smoking. Unfortunately, he proceeded to miss multiple appointments since February. Today, he presents with a hole in his left buccal mucosa that has grown pseudomonas in the past. He is having trouble speaking and breathing. He wants to discuss options for opening his airway so that he can speak again. He still continues to chew tobacco once a week.
While both balloon dilation and resection can be performed in patients with tracheal stenosis to varying degrees of success, each has different indications and contraindications that must be considered when choosing the procedure. Balloon dilation is best suited for symptomatic stenosis that are not suitable for medical treatment of the cause of the stricture or have failed. It is good in patients that have fibrotic lesions. Less suitable lesions are those secondary to tracheobronchomalacia, inflammation, calcification, or carcinoma. It is also not best for patients with lesions associated with ulceration, fragility, or vascularization due to the risk of rupture. Since there is no limit to the length of stricture that can be dilated, even longer lesions have the option for balloon dilation; however, it is limited to lesions above the second order of bronchi because more distal lesions may be harder to access and provide less relief. There are not many contraindications to balloon dilation, but they are similar to flexible bronchoscopy. It is contraindicated when anticoagulants or antiplatelet agents are actively being used or when the airway beyond the point of stenosis cannot be visualized or is too narrow. Intubation and mechanical ventilation are not contraindications for this procedure. 1
The indications for tracheal resection vary slightly with tracheal resection. Lesions that occur after intubation are the most common reason for this procedure. A mass (most often squamous cell carcinoma) may also be an indication. Others include tracheoesophageal and tracheal innominate fistulas. Contraindications include medical considerations for any extensive surgery or general anesthesia, pulmonary dysfunction, problematic anatomy, such as the distance from the right distal trachea to the proximal medial left mainstem exceeding 4 cm, and tracheal resection involving over half the trachea. A relative contraindication is prior irritation and may involve a flap such as pleural, intercostal muscle, or omental wrapping. 2
Previously, dilation was done using rigid bronchoscopy; however, today, many cases are done using flexible bronchoscopy and balloon catheters. Unlike resection, dilation is typically done with topical anesthesia and procedural sedation. It is only done under general anesthesia in the setting of significant airway edema and acute obstruction due to obstruction and risk for airway complications. First, the size(s) of the balloon catheter should be established. These are nonconformal balloons which are stiffer and more easily dilate the stenosis. Consideration should be taken to determine the balloon length, to ensure that it can go beyond the end of stenosis, and diameter, to adequately dilate without injuring the airway. Once all the materials have been chosen, the catheter is passed through the bronchoscope. It can be placed over a guidewire if the provider chooses, and, in this case, the bronchoscope is reinserted, so the airway can be directly visualized during inflation. Next, the balloon is inflated to pressures between 45 and 131 psi using saline. The amount of pressure used is established by the balloon chosen since the diameter is proportional to the pressure. This is done gradually over several minutes to avoid rupture or over dilation. It is then inflated for up to two minutes to allow for dilation and deflated. Once the balloon is deflated, the response is visualized by the bronchoscope. Should the result be less than desired, dilations can be repeated with the same balloon or a wider balloon and inflation times increased. Once the dilation is successful, the bronchoscope and balloon are removed. This is typically a same day procedure, but patients may stay overnight if there is concern for maintaining an adequate airway. 1
Tracheal resection can be done for either carcinoma, mass, or stenosis in various patients. The most common approach is through a low collar incision. If more exposure is required, the incision can be extended and divide the manubrium, but, fortunately, a full sternotomy is rarely required. The thyroid cartilage is exposed through elevating the superior skin flap and the isthmus is divided and retracted laterally to improve exposure. The dissection is started laterally and is kept on the trachea by retracting the thyroid allowing recurrent nerves to fall away and avoid injury without the need for identification. The distal airway is controlled using the appropriate size metal reinforced Tovell tube. Then a small rubber catheter is secured to the endotracheal tube to maintain control of the oral tube. This allows for easy retrieval of the endotracheal tube when the procedure is complete. Next, the damaged trachea can be resected while looking for tension until good airway is reached. After, circumferential dissection is done, and care is taken to ensure that no recurrent nerves or esophagus is damaged. If needed, a nasogastric tube can be placed to identify the esophagus. Next, proximal and distal traction sutures are placed in the mid lateral airway. This helps with approximation and is done to make sure the airway can be properly anastomosed with the given tension. A suprahyoid laryngeal release can be done if the tension is found to be too excessive. 3
Once the trachea has been resected, anastomosis can be performed. Anastomotic sutures are placed approximately 3 to 4 mm in depth and 3 to 4 mm between the sutures. The first is typically placed at 6 o’clock of the proximal distal airway. The next sutures are placed inside the previous and clipped in caudal fashion to the drapes keeping each untangled. The first segment is done from the 6 o’clock suture to the lateral traction suture with the anterior row placed last. Once all the anastomotic sutures are in place, the airway is suction, the thyroid bag is deflated, and the endotracheal tube is advanced with the rubber catheter. Once the endotracheal tube is advanced into the distal airway, the sutures are examined to make sure there is no entanglement. Next, two or three folded blankets are used to flex the neck, allowing the proximal airway to descend and the two ends easily approximate. Now the traction sutures can be tied on either side by pulling the anterior sutures in opposite directions. After all sutures have been tied, the anastomosis is checked to ensure it is air tight by suctioning in the mouth of the patient. Next the balloon is deflated and insufflated to 20 and 40 cm pressures of water in the endotracheal tube. Air should be heard moving through the tube and the mouth. Of course, any air leak outside the trachea should be repaired. The strap muscles then serve as a buttress and help avoid the occurrence of infection or tracheoinnominate artery fistulas. Lastly, a drain is placed, and the wound is closed. Care should be taken to ensure the neck is not over flexed, and the patient is woken from anesthesia. After one week the patient should have a repeat bronchoscopy to check and make sure the anastomosis is holding. 3
As with any procedure, complications are always possible. Typically, balloon dilation with flexible bronchoscopy is well tolerated. Minor complications may include chest pain during dilation or bronchospasm or atelectasis during the procedure. The balloon could be over dilated and lead to a lacerated or ruptured airway and cause hemorrhage, pneumothorax, pneumomediastinum, or mediastinitis, but these complications are rare and typically self-limiting and require conservative treatment. At this time, no mortality with this procedure has been noted. As expected, restenosis is also possible. 1
Complications involving a tracheal resection are more severe than those of dilation. They can be classified as anastomotic or non-anastomotic complications. Anastomotic typically includes formation of granulation tissue, restenosis, anastomotic separation of varying degrees, and possible fistula formation such as with the innominate artery or the esophagus. Non-anastomotic complications are often more specific to the upper airway reconstruction. They may involve laryngeal edema or glottic dysfunction including problems with phonation and swallowing. The incidence of complications is about 20%, and half of these cases involve anastomotic complications but can typically be managed with aggressive treatment to result in a satisfactory airway. Unfortunately, anastomotic complications have thirteen times more incidence of mortality following resection. Incidence of complications are higher in patients with tracheomalacia with focal stenosis. This is also true for stenosis related to Wegner’s granulomatosis. Patients who have a history of tracheoesophageal fistulas or post intubation stenosis are also at a higher risk of complication than those with tumors. The increased incidence with tracheoesophageal fistulas is most likely due to the pathology and high burden of comorbid conditions. Those with post intubation trauma stenosis tend to have a longer segment of the trachea involved leading to inflammation and adhesions. 4
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Now that the indications, contraindications, procedure, and complications have been outlined, it is important to examine the efficacy of each treatment in regard to benign tracheal stenosis. A study from the journal of Clinical and Experimental Otorhinolaryngology examined the long-term results of endoscopic airway dilation. The examiners found that endoscopic dilation cured approximately 41%, improved 46%, and failed to be effective in 13% of patients. Better outcomes were discovered in patients that had mild stenosis or a shorter segment. It was most effective for those with isolated stenosis with a cure rate of 72%. 5
The efficacy of tracheal resection was examined by providers in the Annals of Cardiothoracic Surgery. They looked at 119 patients, 47 of which underwent resection and reconstruction. The overall success rate was 92% for all groups and patients experienced significant improvement of quality of life compared to preoperative conditions. The reported mortality rate is up to 2% with more airway related complications involved in the laryngotracheal resection and reconstruction versus segmental tracheal surgery. 6
These two studies prove that it is essential to choose the correct patient for the selected procedure. Both have good degrees of success, but only in the appropriate setting. Patients with long or more severe stenosis my not be good candidates for balloon dilation as their primary or singular procedure. However, resection may be too severe a procedure for symptomatic patients with only mild or shorter stenotic segments.
It is now important to revisit Dr. Greene’s patient to evaluate the best procedure for Mr. PL at this time. He has already undergone suspension of microdirect laryngoscopy, esophagoscopy, and dilation. During this procedure the was found to have near 100% stenosis 2cm below his vocal cords. The lumen was identified but unable to pass the balloon dilator. At his most recent visit, a tracheal resection with T tube skin graft placement was chosen. The patient was told he would likely have to stay in the hospital 7-10 days to monitor for complications that could be fatal such as airway issues that may require tracheostomy tube replacement. The surgery was planned for late June.
After examining the patient’s history and the indications, complications, and success rates of both balloon dilation and tracheal resection, it is clear tracheal resection is the best option for Mr. PL. He has severe stenosis of nearly 100% and a long segment greater than 2 cm. No tracheoesophageal fistula was found at that time. Taking into consideration the previous studies and his prior attempts, it is clear balloon dilation will not be effective as the primary treatment for his stenosis. Even though the risks for this procedure are greater due to his history of post intubation stenosis, it is clear he may only get relief by removing the stenotic section. The high chance of complications was discussed with the patient to ensure he believed he was symptomatic enough for it to be worth the risk. He understood, and, therefore, Mr. PL underwent a tracheal resection with limited intraoperative complications. He is now being monitored post-operatively at UAB hospital for anastomotic complications that could lead to morality.
Works Cited
- Colt MD H. Flexible bronchoscopy balloon dilation for nonmalignant airway strictures. UpToDate. https://www.uptodate.com/contents/flexible-bronchoscopy-balloon-dilation-for-nonmalignant-airway-strictures-bronchoplasty. Published 2019. Accessed June 20, 2019.
- Mueller MD D. Tracheal Resection. Medscape. https://emedicine.medscape.com/article/1969880-overview#a3. Published 2018. Accessed June 20, 2019.
- Mathisen MD D. Tracheal resection and reconstruction: How I teach it. Ann Thorac Surg. 2017;103(4):1043-1048. doi:10.1016/j.athoracsur.2016.12.057
- Auchincloss H, Wright C. Complications after tracheal resection and reconstruction: prevention and treatment. J Thorac Dis. 2016;8(2):160-167. doi:10.3978/j.issn.2072-1439.2016.01.86
- Oh S, Park K, Lee S. Long-Term Results of Endoscopic Dilatation for Tracheal and Subglottic Stenosis. Clin Exp Otorhinolaryngol. 2014;7(4):324. doi:10.3342/ceo.2014.7.4.324
- Timman S, Schoemaker C, Li W et al. Functional outcome after (laryngo)tracheal resection and reconstruction for acquired benign (laryngo)tracheal stenosis. Ann Cardiothorac Surg. 2018;7(2):227-236. doi:10.21037/acs.2018.03.07
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