Overview of Tracheal Resection
The techniques used to help patients breathe using mechanical ventilators, or breathing machines, have evolved since their invention in the 1800s. One significant development was the idea of bringing air into the lungs under positive pressure. This technique, which began as a solution for fighter pilots breathing at high altitudes during the 1940s, was quickly adopted to help patients suffering from polio, especially during a large outbreak in Scandinavia. A major milestone came in 1950 when Engstrom developed one of the first devices to use positive pressure. This ventilator worked by directing air into the patient’s windpipe (or trachea) through a tube. The design and use of these machines have evolved greatly since then.
At first, the tubes used to carry air to the trachea were low-volume, high-pressure tubes. Not long after their introduction, doctors noted complications that could arise from using these tubes for an extended period. Conditions such as damage due to lack of oxygen supply (ischemia), tissue death (necrosis), and narrowing of the trachea due to scarring were linked to long-term use of the tubes, high cuff pressures, and excessive movement of tubes inserted into a hole in the windpipe (tracheostomy tube).
For a long time, surgeons believed it was impossible to operate on the cartilage in the patient’s windpipes due to its natural rigidity and poor blood supply. But in groundbreaking efforts, Dr. Hermes Grillo and Dr. Joel Cooper demonstrated that it was indeed possible to remove (resect) the narrowed (stenotic) sections of the trachea and reattach (anastomose) the ends. This discovery spurred further progress in managing patients’ airways during surgery and advanced techniques for attaching the ends of the trachea to reduce tension.
Today, a surgical procedure called tracheal resection with primary anastomosis is performed at major hospitals by a team of specialists, including anesthesiologists, ENT (ear, nose, and throat) doctors, cardiothoracic surgeons, and experts in pulmonary and critical care. Initially, this surgery was used to treat tracheal stenosis (narrowing of the windpipe). But it is now also used to treat various other conditions, including tracheal tumors, tracheomalacia (weakening of the windpipe walls), tracheal injuries, and abnormal connections between the trachea and either the esophagus or innominate artery.
Anatomy and Physiology of Tracheal Resection
The trachea, often known as the windpipe, is a tube like structure in our throat with a sort of ‘D’ shape. It has 16 to 20 incomplete rings, shaped like a horseshoe, made out of a special kind of tissue known as cartilage. This tissue gives the trachea its unique shape. The trachea sits in front of the esophagus (the food pipe) and is connected to each other using membranes.
The trachea starts from below a piece of cartilage called the cricoid, and extends downwards to an area known as the carina. This tube is about 10-13 cm long on average in adults. Above the trachea is another structure called the larynx, which houses parts such as the arytenoid, corniculate, and cuneiform cartilages, along with the epiglottis, thyroid, and cricoid.
A nodular cartilage structure known as the arytenoids sit upon the cricoid. These all serve as the point of attachment for the muscles and ligaments that help us speak. A nerve called the recurrent laryngeal nerve attaches to the larynx and trachea, which is often at risk during medical procedures like thyroid removal.
The trachea is provided with blood through a chain of blood vessels that travel along the tracheal wall. This blood supply is important to maintain during surgeries to ensure the trachea gets the oxygen and nutrients it needs. Another important point during surgery is to avoid reducing blood flow to the trachea which may lead to tissue death.
A potential complication that can arise after an endotracheal tube, commonly known as a breathing tube, is placed is something called stenosis. This is a condition that causes the trachea to narrow and can happen in about 10% to 22% of all cases, with only 1% to 2% showing symptoms.
Stenosis can also occur on its own over a long period of time, and the symptoms include shortness of breath on exertion, cough, wheezing, coughing up blood or shortness of breath. It is interesting to note that the trachea can be up to 75% narrower than usual before any symptoms show up. Sometimes, symptoms of stenosis can be mistaken for asthma because of the slow growth of some tracheal tumors. Surgery to remove the trachea is typically the best way to treat malignancies and extensive stenosis that doesn’t respond to other treatments.
Why do People Need Tracheal Resection
Tracheal resection is a medical procedure that removes a part of your windpipe, also known as the trachea. This procedure is most often done to treat a condition called acquired stenosis. This typically occurs as a result of having a breathing tube placed in the windpipe for a long time or due to a surgery called a tracheostomy, which is when a hole is made in the neck to help you breathe. About 6% to 21% of people who have had prolonged intubation (a breathing tube), and around 0.6% to 21% of people who have had a tracheostomy, wind up having this condition. If you’re an adult in the US, there’s a 4% to 13% chance of acquiring stenosis after having a breathing tube, and for newborns, it ranges from 1% to 8%. Treatments such as balloon dilation (where they expand your windpipe using a medical balloon) or using lasers to remove scars can sometimes help, but when these treatments don’t work or the problem keeps coming back, the doctor may suggest tracheal resection. This surgery has a high success rate of 71% to 95%.
Another reason you might need a tracheal resection is if you have cancer in your windpipe. These types of cancers are very rare, making up less than 0.01% of all tumors and 0.2% of cancers in the respiratory tract (the parts of your body that help you breathe). The two most common types of tracheal cancers are squamous cell carcinoma, which makes up 50% to 66% of all tracheal tumors, and adenoid cystic carcinoma, which represents 10% to 15%. Other, less common types of tracheal cancers include mucoepidermoid carcinoma, nonsquamous bronchogenic carcinoma, sarcoma, carcinoid tumors, and melanoma. If thyroid cancer has spread to your airways, a tracheal resection can also help improve your chance of survival.
Other reasons for a tracheal resection might include damage to the airways due to injury or burns from inhaling hot air or radiation, birth defects or infections in the trachea, fibrosis (scar tissue) in the cartilage of the trachea, and other unknown causes such as idiopathic laryngotracheal stenosis (a rare condition where your windpipe narrows without any known cause).
When a Person Should Avoid Tracheal Resection
Sometimes, certain conditions might prevent a person from being able to undergo tracheal resection, a surgery that involves removing a part of the windpipe. These conditions include:
• One situation is if a surgical team needs to remove more than half of the windpipe due to the presence of a lesion. In this case, tracheal resection might not be possible.
• Severe medical comorbidities. This means the person has multiple health problems at once which may increase the risks associated with the surgery.
• Reduced pulmonary function is also a reason. This means the person’s lungs are not working as well as they should be, which can complicate a surgery like tracheal resection.
• If the person had neck or chest radiation treatments in the past and now requires a “flap reconstruction”, a specific type of plastic surgery, a tracheal resection may be imprudent. This is because radiation can affect healing and may complicate the surgery.
• Lastly, if the person has distant metastatic disease, tracheal resection might not be viable. This means the person’s cancer has spread to places far from the original cancer site and a more broad treatment method might be necessary instead of focusing on the windpipe alone.
Equipment used for Tracheal Resection
To properly carry out a surgical procedure known as tracheal resection, several tools and materials are required. Here’s what they are and their purposes:
* Laryngoscope: This is a tool used to examine the back of your throat, including your voice box and vocal cords.
* Rigid bronchoscope: This is a tube-like device used to see inside your windpipe and lung passages.
* 0° and 30° Hopkins rod: These are slim, lighted instruments used to improve visibility during the procedure.
* ETTs in multiple sizes, regular and wire-reinforced: ETT stands for endotracheal tubes. These tubes, which come in different sizes, are inserted into the windpipe through the mouth or nose to help a patient breathe.
* Tracheal or esophageal balloon: This is used to prevent air or fluid leaking during surgery.
* Surgical instruments for neck dissection: These are special tools used when removing tissue in the neck.
* Sternotomy tray: This is a set of surgical tools used when making an incision in the breastbone.
* Surgical instruments for thoracic dissection: These tools are used when removing tissue from the chest area.
* Suture for tracheal anastomosis and Grillo sutures: These are special sewing materials used to connect separated pieces of the windpipe or other structures.
* Absorbable 3-0 polyglycolic (Vicryl), 4-0 polydioxanone: These are types of stitches that will break down on their own over time.
* Nonabsorbable 0 Silk, 2-0 polypropylene (Prolene): These are types of stitches that will not dissolve and might need to be removed later.
Who is needed to perform Tracheal Resection?
A tracheal resection, which is a procedure to remove a part of your windpipe, requires several healthcare professionals to ensure it runs smoothly and safely. Firstly, we have the surgeon. This is the main doctor performing the operation.
Then, there is a surgical assistant who helps the surgeon during the procedure. We also have an anesthesiologist, a special kind of physician who will mind your comfort, making sure you don’t feel any pain or discomfort.
You will also have a surgical technologist in the room who manages the equipment, ensuring everything needed is available and properly working. Lastly, there’s a circulating nurse who coordinates the entire procedure, making sure everyone and everything is in the right place.
These professionals are all a part of your surgical team -their main goal is to ensure your safe and smooth surgery, and equally important, your comfortable recovery.
Preparing for Tracheal Resection
Before a patient goes through surgery to treat a condition of their windpipe (also known as trachea), they need a CT scan. This scan shows the doctor the exact size and place of the problem in the trachea. In some cases, the scan is done during both inhaling and exhaling, to evaluate the way the trachea changes shape when a person breathes (this is done in a condition called tracheomalacia). Another type of CT scan, which includes a special dye (contrast), is used to check if a tumor has spread in the neck and chest.
Before going through with the surgery, the doctor will explain to the patient all the possible risks. These can include bleeding, infection, the narrowing of the windpipe following the surgery, wound complications, and the possible need for additional surgeries in the future. After the surgery, the patient might be put on a breathing machine (this is called intubation) and given medicine that helps them sleep (sedation) for a few days. This is usually done in the Intensive Care Unit (ICU). This allows the stitched part of the trachea to heal properly. Also, the patient’s chin may be stitched to their chest to keep their neck bent. This is all part of the healing process.
During surgery, the doctor will access the windpipe via the neck which is a sterile (germ-free) procedure. They may also perform a bronchoscopy, which involves inserting a small tube with a light and a camera into the lungs through the nose or mouth, to check the inside of the airways. During the operation, the inner lining of the airways and the soft tissues of the neck are reconnected.
The surgeon will decide how best to prepare the patient for the procedure. This includes deciding on the use and choice of antibiotics to prevent infection post-surgery.
How is Tracheal Resection performed
Airway Management
If you have a narrowing of your windpipe, known as ‘airway stenosis,’ the doctor may consider a surgical procedure to widen it or remove the narrow segment. This surgical procedure is called tracheal resection (removal of part of the windpipe) or cricotracheal resection. The following description explains the steps your medical team may take during this procedure.
Firstly, a tube must be inserted into your windpipe through the mouth to help you breathe; this step is called intubation. Your doctor can use a special tool to allow them to see clearly during the procedure. If it’s very hard to insert the breathing tube because the windpipe’s narrow part is too small, the doctor might need to make a cut in your neck to create a new air passage, called a tracheostomy.
Next, a device is used to inspect your voice box, windpipe, and the narrow part. Three measurements are taken: the distance from your voice box to the point where your windpipe splits into the lungs, the distance from the narrow part to this point, and the length of the narrow part. These measurements will help plan the surgery.
After ensuring that the airway is safe, the surgery begins. The doctor will make a cut on your neck and proceed to uncover the narrow part of your windpipe. When it is all prepared, the doctor will make a hole in your windpipe below the narrow area, and a special tube will help you breathe during the surgery.
The narrow portion will be removed completely. A tube is then threaded through the mouth and secured to the windpipe above the area where the narrow area was removed. After this, the gap that was left by the removal of the narrowed segment will be stitched back together.
This stitching process is done carefully, starting at the backside and moving towards the front. When the stitching is finished, a test will be performed to make sure there is no leakage of air from the stitched up area. If there’s any leakage, the doctor will make some more stitches to seal it properly.
Remember, every individual’s body and condition is different. Your doctor will explain how this procedure applies to your unique situation.
Possible Complications of Tracheal Resection
Patients who undergo surgery on their windpipe, or tracheal resection, typically stay in the hospital for about 8 days. This surgery has a high success rate—about 95%—but it also has some risk of complications, which happens in roughly 18.2% of cases.
The main problem after surgery is related to tension on the line where the doctor stitches the trachea back together. This can cause problems like restenosis (the trachea becomes narrow again), tracheal wound dehiscence (the wound splits open), and anastomotic leak (leakage from the spot where the trachea was reconnected). To avoid such complications, the neck is kept positioned to help the wound heal without tension. Some methods to achieve this include a Grillo stitch (a special type of suture), ventilation with relaxation medicines to keep the neck muscles relaxed, a neck brace, and a plaster splint for the back of the neck. But, these methods can also extend the hospital stay and increase the risk of other health problems.
When it comes to breathing after the surgery, the breathing tube may be removed right away or within a week, depending heavily on the patient’s age, health status, and how much of the trachea was removed. A windpipe opening called a tracheostomy can be created if the surgeon believes the tube can’t be removed early.
After surgery, controlling nausea is important to prevent throwing up, which can cause the neck to stretch backwards and possibly lead to inhaling vomit into the lungs. Medications are used for this, as well as for pain. Patients may be asked not to speak for a while to prevent throat swelling. Eating will resume only after a type of x-ray test and speech therapy.
In some cases, patients can experience problems like difficulty swallowing due to the surgery, and changes in voice quality if the area near the vocal cords was operated on. The area that was stitched will be checked on the 7th day after surgery, and earlier if there are symptoms like a whistling sound when breathing, voice changes, wound infection, neck swelling due to air that has leaked out of the windpipe, or excessive mucus.
Restenosis may occur in up to 10% of patients and is the most common complication of surgery due to factors like growth of healing tissue at the suture line or removal of lesser normal tissue during surgery. Symptoms may take several months to appear, that is why regular monitoring with a simple procedure called bronchoscopy is recommended. Treatment for early restenosis involves ballooning the narrowed area, medication inhalers, local injection of steroids into the area of overgrowth of healing tissue, or stents that release anti-inflammatory drugs. Erythromycin is another commonly used treatment for tracheal restenosis due to its anti-inflammatory effects. If the narrowed area does not respond to repeated treatments, repeat surgery or long-term T-tube stenting may be required.
A rare but potentially deadly complication is wound splitting, which occurs most commonly at the front wall of the trachea. Small wound splitting can be managed with voice rest, keeping the neck bent forward, antibiotics, feeding with a tube passed into the stomach, and possibly re-intubating with the cuff of the tube below the line of surgery. Larger wound splitting requires direct intubation to prevent separation of the windpipe and returning to the operating theater for re-suturing the wound. A temporary tracheostomy or T-tube stent might be placed if reanastomosis cannot be done.
Swelling of the throat is more common in patients who underwent surgery involving the crico-tracheal area and can last for 1 to 2 weeks. Stridor (a high-pitched wheezing sound), and voice change should be evaluated with a bronchoscope. Wound infection can present with redness, discharge, and increased pain, and is managed with antibiotics and scans to assess for air and fluid collection around the windpipe.
Some more rare complications include fistula formation where abnormal tunnels are formed with the anterior wall of the trachea to the artery or with the posterior wall to the esophagus, injury to the RLN (Recurrent Laryngeal Nerve) that controls the voice box, heart attacks, blood clots, and prolonged hospitalization. Tracheoinnominate fistula is a life-threatening complication requiring surgery.
A group analyzed outcomes in adults who underwent specific tracheal surgeries and found that the hospital stay was around 7 days, with 28% experiencing at least one adverse event. Some patients needed extended hospital stays, battled pneumonia, wound infections, and wound splitting. A number of patients needed unplanned second surgeries and some patients had to be readmitted within 30 days. There were no deaths in this particular study. They also found some factors that increased the risk of complications such as being classified as an American Society of Anesthesiologists class III, having a pre-existing lung condition called chronic obstructive pulmonary disease, having contaminated wounds before surgery, preoperative breathing difficulty, and long-term steroidal use.
What Else Should I Know About Tracheal Resection?
Surgical methods for treating airway issues and the understanding of the effects of machine-assisted breathing have greatly advancedwithin the last 50 years. Despite this, narrowing of the windpipe, called tracheal stenosis, still poses a big challenge.
Healthcare experts who handle such airway problems need to have extensive knowledge about managing the airway, understanding the cause of the disease, familiarity with the structures in the area, how to diagnose the condition, techniques to surgically repair it, how to care for the patient after surgery, and ways to lessen complications.
Thus, improvements in medical technology and knowledge can continue to help in dealing with complex conditions like tracheal stenosis.