Complex Tracheal Surgical Interventions and Innovations
Airway disorders involving trachea has varied presentations and causes, but surgery is the main stay for most scenarios. Trauma, long-term intubation, airway interventions, inflammatory diseases and neoplastic masses are a few causes of the obstructive lesions.
We summarize the airway reconstruction anesthetic protocol at University of Florida for adults with airway compromise with more than decades long history of tracheal stent dependency after tracheal resection and associated distal critical stenosis. Patients present with longterm intolerance to exertion, hemoptysis and dyspnea like symptoms. Due to the distal and critical stenosis of airway, femoral venous cannulation for extracorporeal oxygenation is accomplished after spinal anesthesia. Then extracorporeal anesthesia is used with right thoracotomy and cervical tracheal release. Stenosis and tracheal lesion is resected and airway intubation completed and anastomosis performed.
Clinical cases of tracheo-oesophageal fistula (TEF) repair in adults after long-term intubation, trauma and poor nutrition need tracheal resection and repair around the existing endotracheal tube with closure of the fistula. Surgical repair includes additional unique pedicle flaps. Muscle flaps pedicled to neck, intercostal origin, omental, cardiac sac, alloplastic mesh, sheets, glue are described. We describe the Thymic fat pad (TFP) flap for reinforcement of the TEF repair along with muscle flaps along with review of literature on TEF and surgical techniques. There is no reported literature for use of this TFP flap for TEF closure. We utilize this TFP flap successfully for traumatic TEF repair and tracheal resection. This flap was described to cover the left internal thoracic artery after cardiac bypass. Its use to prevent fistula leak and tracheal anastomosis vascular cover is beneficial.
Tracheal neoplastic lesions are insidious in onset. At University of Florida work up includes bronchoscopy and virtual bronchoscopic image reconstruction and three-dimensional rendition from the computed tomographic imaging. Biopsy may not be indicated prior to resection. PET scans are not avid in Adenoid Cystic Carcinoma when compared to Squamous cell carcinomas. Malignant lesions of trachea are mostly metastatic and extension of tumors and a small percentage include primary lesions. Squamous Cell Carcinoma is common, followed by adenoid cystic carcinoma as primary tumors of the trachea
In conclusion tracheal resections and reconstructive techniques are fraught with various complications. Due to the two point anatomical fixation and segmental vascular supply. Preoperative challenges of patients include poor pulmonary reserve, poor nutrition, diabetes mellitus, polytrauma, previous surgical attempts etc. The anesthetic limitations are encountered in pre, peri and postoperative situations with complex tracheal reconstructions for distal critical stenosis. We present resection lengths of 4cm and more with use of carinal and cervical mobilization and primary closure. Healing potential was enhanced with TFP flap and early physiotherapy and nutritional monitoring while on ventilator. The patients who failed extubation had planned tracheostomies after adequate confirmation of healing. Future innovations include longer segment repair with optimized tracheal transplants and increase in disease free survival.
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