Post-Intubation Tracheal Stenosis: Tracheal Resection With Dorsal Mucosectomy and Primary Anastomosis

The Patient

This patient is a thirty-four-year-old man with a previous history of heart surgery during childhood and used a pacemaker. He had a car accident in August 2022 with traumatic brain injury and a need for orotracheal intubation. He remained intubated for five days with conservative treatment for the neurological injury and was hospitalized for four weeks to treat fractures with orthopedics. 

One month after discharge, the patient developed progressive dyspnea and stridor. A bronchoscopy revealed subglottic stenosis approximately 2 cm from the vocal folds, at the height of initial tracheal rings. A complementary neck CT confirmed the findings. He underwent three tracheal dilations, with a two month interval between them, but symptoms returned. Tracheal resection with primary anastomosis was indicated.

The Surgery

The procedure started with suspension laryngoscopy for airway evaluation and more precise location of stenosis. Orotracheal intubation and passage of a nasogastric tube was performed to facilitate location of the esophagus. The patient was then positioned in a supine position with a subscapular pad and the neck extended.

A transverse cervicotomy was performed above the sternal notch with dissection in planes up to the laryngeal cartilages and pretracheal fascia. Digital release of the pretracheal fascia was performed for superior mobilization of the trachea, which would facilitate anastomosis. Anterior tracheotomy allowed for direct visualization of the region of stenosis and decision on the segment to be resected. The orotracheal tube was pulled superiorly, with a new sterile tube passed through the surgical field for ventilation. 

After resecting the stenotic segment, a wide tracheal lumen suitable for reconstruction was located. Cricoid involvement was then treated through dorsal mucosectomy, preserving the cricoid plate and protecting the recurrent laryngeal nerves. Two points of repair were performed with 2-0 Vicryl to approximate the segments to be anastomosed. The anastomosis began on the posterior wall, with a 4-0 PDS (polydioxanone) thread in a continuous suture, removing the tube with periods of apnea to facilitate execution. 

Next, the anterior wall anastomosis was performed with separate single sutures of 4-0 PDS. Due to the proximity of the anastomosis to the vocal folds and the risk of edema due to manipulation, a protective tracheostomy was performed through an inferior counteropening, which was planned to be removed during an early outpatient return. The upper orotracheal tube was passed inferiorly and the anterior wall anastomosis was completed. A muscle flap was performed to protect the anastomosis line from the risk of tracheoinnominate fistula. 

After completing the procedure, the patient was extubated and taken to the ICU where he was monitored for 24 hours. He was discharged from the hospital seven days after the procedure, using Levofloxacin due to tracheal secretion.

Upon outpatient return after three months, the patient underwent bronchoscopy, which revealed a wide tracheal lumen and a well-positioned tracheostomy. Decannulation was performed without complications. After a six-month follow up, the patient remained stable and had no signs of stenosis recurrence.

References

1. Evermann M, et al. A novel technique of voice-sparing cricotracheal resection. JTCVS Techniques 2023 19.
2. Evermann M, Schweiger T, Roesner I, Denk-Linnert DM, Klepetko W, Hoetzenecker K. Established and innovative surgical techniques for the treatment of benign subglottic stenosis. Transl Cancer Res 2020;9(3):2136-2141. doi: 10.21037/tcr.2020.02.76
3. Grillo HC. Primary reconstruction of airway after resection of subglottic laryngeal and upper tracheal stenosis. Ann Thorac Surg 1982;33:3-18.
4. Hoetzenecker K, Schweiger T, Roesner I, et al. A modified technique of laryngotracheal reconstruction without the need for prolonged postoperative stenting. J Thorac Cardiovasc Surg 2016;152:1008-17.
5. Liberman M, Mathisen DJ. Tailored cricoplasty: an improved modification for reconstruction in subglottic tracheal stenosis. J Thorac Cardiovasc Surg 2009;137:573-8; discussion 578-9.

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