European Journal of Cardiovascular Medicine

Tracheal stenosis is characterized by cicatricial narrowing of the endotracheal lumen [1]. This condition can arise due to various factors, including injury produced due to intubation, trauma, gastroesophageal reflux, Wegener's granulomatosis, connective tissue diseases, or unknown causes [2]. Advancements in anaesthesia, surgical techniques, and comprehension of tracheal pathophysiology have made tracheal reconstruction a safer procedure [3]. Despite recent advancements in endotracheal and tracheostomy cuff design, tracheal stenosis following intubation still constitutes a significant risk for tracheal obstruction, with its incidence rising recently, which can lead to life-threatening consequences [4]. Tracheal reconstruction and replacement are critical in addition to being an intricate surgical procedure indicated for various conditions, including primary tracheal neoplasms such as thyroid cancer and squamous cell carcinoma, large tracheoesophageal fistulas, ineffective prior surgeries of the trachea (e.g., restenosis or long-standing stenosis that has enlarged), and, on rare occasions, inborn tracheal stenosis [5]. When the extent of tracheal resection crosses half the length in adults or one-third of the same in children, tracheal resection with end-to-end anastomosis becomes inadequate once the adjacent structures are removed. In such cases, tracheal replacement using a substitute becomes essential to facilitate the restoration of a healthy airway [5]. However, it's important to note that while reconstruction offers favourable results in most cases, anastomotic complications remain and are linked to both morbidity and mortality [6]. There are no well-defined criteria for what length of trachea can be resected during tracheal reconstruction, as this depends on individual assessment of a variety of factors, namely, maximum height achieved by trachea out of the chest during greatest neck extension and whether adequate length can be achieved after surgical release. However, it is to be noted that resections of less than 4 cm of the trachea are universally acceptable unless complicated by other features [7,8]. Here, we present five cases of tracheal reconstruction following stenosis performed at one of India's first newly opened Thoracic Surgery tertiary care centres.

Patient 1:

A 24-year-old gentleman reported to the Thoracic Surgery outpatient department, complaining of a history of breathing difficulties for 20 days. He had previously been hospitalized for eight days on ventilatory support following a snake bite. Clinical examination revealed the presence of an inspiratory stridor. CECT of the neck and thorax revealed the presence of tracheal stenosis (Figures 1, 2). As the stenotic segment was approximately 6 cm in length, a full sternotomy was performed with the division of the inferior pulmonary ligament, hilar U-shaped release, B/L bronchial release and infrahyoid release. After this trachea was mobilized, the stenotic segment was resected, and an end-to-end tension-free anastomosis was done (Figure 3). Grillo’s stitch was placed, and the patient was extubated after 48 hours. Post postoperative course was uneventful except for the husky voice.

 Patient 2:

A 30-year-old male presented to the emergency department following a self-inflicted injury of the neck that caused an infra-glottic stenosis of the trachea. A tracheostomy was performed. Subsequently, the patient developed post-intubation tracheal stenosis. CECT revealed stenosis in the lower part of the trachea, just at the level of D3 (Figure 4). A cervical collar incision and partial sternotomy managed this. The stenotic segment was identified, dissected and tension-free end-to-end anastomosis was done. Grillo’s stitch was placed, and the patient was extubated after 48 hours. The postoperative course was uneventful.

 Patient 3:

A 22-year-old boy presented to the Thoracic Surgery department with an alleged history of a self-inflicting injury to the neck with a sharp knife, with an open wound on the anterior aspect of the neck with a tracheostomy site. The patient had a two-month history of untreated depression. The evidence of tracheostomy was noted— cuffed tracheal tube no.7 was present in situ, and Ryle’s tube (inserted via the left nostril) was seen in the pharynx. Diffuse laryngeal wall oedema and luminal compromise were evident. A contrast-enhanced computerized tomography (CECT) of the neck revealed a defect of 14mm, just above the level of the thyroid cartilage, and focal defects were seen in the soft tissue of the neck communicating with the lumen of the larynx. Upper GI Endoscopy was normal. This was confirmed as a case of supraglottic tracheal injury. Bronchoscopy revealed normal vocal cords and mild oedema in the anterior tracheal wall above the tracheostomy site. Disrupted sutures from a previous procedure were noted.

Consequently, a repair of the supraglottic cut was conducted, focusing solely on the supraglottic area with tracheostomy in situ. After one month, sequential corking of tracheostomy was done (Figure 5). No distress was noted and the voice of the patient recovered. The postoperative course was uneventful.

Patient 4:

An 8-year-old boy was referred to the Thoracic Surgery department as a case of Post intubation tracheal stenosis. He had a history of scrub typhus fever and was intubated; he was extubated and discharged but developed an inspiratory stridor. Tracheal resection (4cm length) and tension-free anastomosis were done. Grillo’s stitch was placed. On post-op day 2, the patient was extubated. He was reintubated after some time without bronchoscopy guidance, which led to the dehiscence of the anastomotic line. A tracheostomy was placed and later planned for surgery.

Patient 5:

An 8-year-old boy was referred to the Thoracic Surgery department as a case of tracheal stenosis post tracheostomy. CECT thorax revealed Tracheal stenosis. Tracheal resection (4cm length) and tension-free anastomosis were done. Grillo’s stitch was placed, and the patient was extubated after 48 hours. The postoperative course was uneventful.

 Surgical steps employed in all the above patients

1. In the operating room, the patient is positioned supine, and their neck is flexed posteriorly and hyperextended, which helps in bringing the trachea out of the thoracic inlet and decreasing anastomotic tension.
2. A cervical collar incision is made on the proximal 1/3rd of the trachea. For lesions located in the middle 1/3rd, a partial or total sternotomy, coupled with a cervical collar incision, is preferred. For the distal 1/3rd lesions, a total sternotomy or a fifth right thoracotomy is done.
3. The dissection is extended circumferentially around the trachea, exhibiting caution to prevent injury to the recurrent laryngeal nerves and the major vessels, and the oesophagus is approached from the posterior aspect. The dissections should not be more than 1-2cm, either proximal or distal to the resection levels, to prevent any inadvertent tracheal ischemia upon revascularization. Traction sutures are tied laterally both superior and inferior to the anastomosis. Before starting the anastomosis, we placed an armoured ET tube in the distal tracheal lumen and ventilated both lungs. For tension-free anastomosis, First, we took the posterior mucosal layer using continuous 3–0 Polydioxanone suture and then interrupted 3–0 Polydioxanone suture in the cartilaginous anterior layer. Just before completing the anastomosis of the anterior cartilaginous layer, we took out the armoured tube and simultaneously placed the new ET tube through the nasal route. We inflate the cuff of the ET tube distal to the anastomosis to avoid pressure over the anastomotic line and confirm it using a bronchoscope.
4. The cervical collar incision was closed in layers, and the head was kept fixed with two strong chin-chest stitches (Grillo's stitch) in the same position for one week.
5. After this postoperative period, a bronchoscopy is done to visualize the anastomotic site and analyze for any postoperative surgery-related technical problems, like loose sutures or bleeding.
6. Follow-up examinations typically involve trachea-bronchoscopy controls, the timing of which depends on the patient's condition and the type of suture used.

Advancements in treatment can sometimes introduce new and challenging complications. Tracheal resection is the preferred treatment option for patients with obstruction above the level of the trachea for mechanical ventilation, suction of secretions in maxillofacial and head and neck surgeries, and to prevent aspiration in case of bilateral vocal cord palsy, significantly enhancing their quality of life. However, many individuals with tracheal stenosis are not suitable candidates for this surgical approach due to underlying medical conditions or intricate airway anatomy. In such cases, non-surgical interventions have gained popularity as an alternative option, particularly for patients with concurrent health issues that preclude them from undergoing surgery [2].

Airway stenosis can develop due to the presence of an endotracheal tube, which increases pressure, resulting in ischemia and subsequent scarring and narrowing of the trachea. Clinical presentation involves acute or chronic shortness of breath, cough, stridor, and expectation of blood in cough [13]. Stridor is a predominant sign, particularly in these iatrogenic cases [14]. In the preoperative assessment, it's crucial to carefully examine the shape and size of the wound, determine the severity of the narrowing, assess the extent of tracheal involvement, and look for any inflammation or swelling around the narrowed area [15].

The occurrence of stenosis after intubation can be decreased by the use of large-size, reduced-pressure cuffs, cautious positioning of the stoma, evasion of wide apertures, removal of bulky or prying ventilator connecting apparatus, and careful attention to the tracheostomy [10]. In supraglottic cuts, where the airway remains patent, there may be no necessity for tracheostomy; instead, the issue can be promptly addressed in emergencies.

Thorough preoperative assessment involves clinical examinations, imaging studies such as Computerized tomography(CT) of the chest with multiplanar reconstruction, and evaluating the length and location of the stenosis, involvement of tracheal segments, mobility and integrity of the vocal cords, the degree and limit of the longitudinal spread of disease, the severity of inflammation, and the presence of laryngeal oedema or laryngomalacia by preoperative flexible bronchoscopy, allowing for proper planning of the procedure [13,16]. 

Currently, the management of choice for postintubation tracheal stenosis is through surgery, the foundation of which lies in tracheal reconstruction to optimally reduce the tension, maintain the patency of the vascular supply, and careful dissection and anastomosis [16]. Patients with iatrogenic stenosis are managed variably in relation to the site of the injury, the grading of the stenosis, the primary airway wound trigger, the succeeding stenosis type, and the occurrence of comorbidities [12]. Tracheal stenosis can be managed in various ways— (1) Tracheal resection and reconstruction (TRR) or Laryngotracheal resection and reconstruction (LTRR)— mostly done in cases of symptomatic circumferential stenosis, which can be both idiopathic or iatrogenic; (2) Tracheal laser surgery— it provides only temporary relief of symptoms, and is not a definitive treatment. In recent times, evidence of laser surgery, rather than worsening the stenosis, has made surgeons choose against using it in their patients; (3) Tracheal dilation—the trachea is widened, using a balloon or specialized tracheal dilators, which again only provides temporary relief (4) Tracheobronchial airway stent—a metallic, silicone, or hybrid stent tube is positioned at the stenosed site to keep the airway patent. This can be used as both short- and long-term treatments for stenosis [17]. The prime limitation in the resection process lies in the extent of the longitudinal spread [13]. The approach in case of such surgeries can be cervical, mediastinal, or even rarely thoracic [13]. In severe Post intubation tracheal stenosis, emergency procedures to relieve airway obstruction may be necessary. Whenever possible, bronchoscopic dilation should be chosen. This has the advantage of minimizing further increase in the stenosis length [18].

Prior tracheostomy can increase the duration of surgery and increase the need for postoperative interventions due to an increase in the length and number of resected tracheal segments. Therefore, it is highly recommended to insert the tracheostomy tube close to the stenotic segment in case of post-intubation tracheal stenosis [19]. Successful tracheal surgery demands strong collaboration between the surgeon and anesthesiologist [13]. Furthermore, it is important to continuously monitor ventilation during the resection, assessing for hypoxia and hypercapnia. In traditional anaesthesia, there is no agreement on the timing of extubation [20]. Some authors suggest immediate extubation, while others propose leaving the nasotracheal tube in place for 24 hours in awake patients, with its tip distal to the anastomosis. Their reasoning is to protect the suture, facilitating safe tracheobronchial cleaning and extubation [20, 21].

 Surgery is contraindicated in case of previous history of local irradiation to the neck, any history of invasive intervention to the trachea, inflammation of the mucosal layers even beyond the field of resection, or if the patient is currently under high-dose steroid therapy [13].

Given the elevated prevalence of post-intubation tracheal stenosis, optimal therapeutic outcomes can be attained through the implementation of a multidisciplinary approach, which includes a combination of surgical interventions, endoscopic treatments, and a coordinated, comprehensive treatment strategy. Although tracheal surgery offers the best treatment, it is important to have proper communication and understanding of surgical procedures between the surgeon and anaesthesia team; otherwise, it will lead to postoperative complications which could have been prevented.

Figure 1: CECT of the Thorax showing stenotic segment extending up to lower trachea (Patient 1)

Figure 2: CECT of the neck showing stenotic segment just below cricoid cartilage (Patient 1)

 Figure 3: Patient having 6 cm of tracheal stenosis (Patient 1)

1. Uppercut end showing laryngeal release
2. Sternotomy with an armoured tube placed in the proximal and distal end
3. Sternotomy with exposed mediastinum and armoured tube placed in the distal trachea for ventilation.
4. Postoperative picture of the patient

 Figure 4: Patient 2

1. Figure showing the intubated distal end of the trachea with armoured tube and partial sternotomy done for resection of the stenotic segment
2. Resected two nips of tracheal rings

 Figure 5: Patient 3

1. A: Closure of supraglottic cut
2. B: Supra glottic closure with tracheostomy (uncuffed) in situ

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