Interact CardioVasc Thorac Surg 2009;8:65-66. doi:10.1510/icvts.2008.184747B
© 2009 European Association of Cardio-Thoracic Surgery
eComment: Tracheal surgery
Karthik Vaidyanathan and
Rajan Santosham
Santosham Chest Hospital, 155 Egmore High Road, Chennai 600008, India
Sixty tracheal resections – single center experience
We read with interest the article by Cordos et al. [1] and the eComment by Barbetakis and colleagues [2]. We have a few comments to make on a few aspects of tracheal surgery. The senior author (RS) has performed more than 350 tracheal resections spanning a period of 28 years. In our experience, it is very uncommon for a patient not to be extubated on the operating table after tracheal resection, whatever the extent of resection. A person who has been breathing spontaneously without mechanical assistance pre-operatively, although with some difficulty will logically not require assistance after the obstruction has been relieved. In situations like poor respiratory reserve or severe pulmonary dysfunction these patients would be accepted for surgery only after careful evaluation and would be palliated by other means, either as temporary measure until the lungs recover or as the final solution if the dysfunction is irreversible. As regards vocal cord edema/ dysfunction, a temporary Montgomery T-tube insertion is much less morbid and leads to lesser ICU and hospital stay than prolonging mechanical ventilation. The decision to insert a T-tube can be taken on the table, either during the reconstruction stage – this will depend on the operator's experience – or after the procedure if a trial of extubation on the table fails and laryngoscopy shows vocal cord edema or adductor spasm.
The other aspect regarding tracheal surgery that has to be emphasized is airway control before the procedure. It has been our preference to place an endotracheal tube in the airway above the lesion for ventilation. In case of very severe narrowing, we do a tracheostomy under local anesthesia, siting the stoma just below the obstruction and including it in the anastomoses and then secure the airway. Femoro-femoral bypass has rarely been required.
Tracheal mobilization is the other critical aspect of tracheal reconstruction. Care should be taken not to injure the esophagus, the recurrent laryngeals or the lateral blood supply to the trachea. Anterior and posterior mobilization is enough in most of the cases but one should not hesitate to do a sternotomy or a right thoracotomy to perform a hilar release or a pericardial incision to gain additional length on the trachea. The morbidity of a tracheal anastomosis under tension is much greater than the morbidity of an additional incision. In fact, in our experience the additional procedure has not caused any problems so far.
We believe that the first opportunity to repair the trachea is the best chance and re-operations always tend to be suboptimal.
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References
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- Cordos I, Bolca C, Paleru C, Posea RD, Stoica R. Sixty tracheal resections – single center experience. Interact CardioVasc Thorac Surg 2009;8:63–66.
- Barbetakis N, Paliouras D, Asteriou C, Tsilikas C. eComment. Early extubation following tracheal surgery. Is it safe? Interact CardioVasc Thorac Surg, doi:10.1510/icvts.2008.184747A.[Free Full Text]
Related Article
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Sixty tracheal resections – single center experience
- Ioan Cordos, Ciprian Bolca, Cristian Paleru, Radu Posea, and Radu Stoica
Interactive CardioVascular and Thoracic Surgery 2009 8: 62-65.
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