Uniportal Non-Intubated Thoracoscopic Distal Tracheal Resection and Primary Anastomosis for Adenoid Cystic Carcinoma

Primary tracheal tumors are rare, with adenoid cystic carcinoma being a common subtype with a tendency for submucosal spread (1). Surgical resection with primary anastomosis is the standard treatment. Minimally invasive techniques, including uniportal video-assisted thoracoscopic surgery (VATS) and non-intubated surgery, aim to reduce perioperative morbidity (2). However, their use in complex airway procedures like distal tracheal resection remains limited. The authors present a case demonstrating the feasibility of this approach.

This case demonstrates a 39-year-old male diagnosed with adenoid cystic carcinoma located 3 cm proximal to the carina. Chest radiography revealed an apical pneumothorax, while computed tomography demonstrated a 2.8 × 2 cm lesion in the distal trachea. Flexible bronchoscopy confirmed the precise location of the lesion, and histopathological examination established the diagnosis.

The patient underwent uniportal non-intubated surgical resection with primary tracheal anastomosis. A superior triangle dissection was performed, followed by identification and preservation of the vagus nerve. The azygos vein was isolated, ligated using a stapler, and its lateral stump was secured to the chest wall. Hilar and pericardial release maneuvers were undertaken to facilitate a tension-free anastomosis. The trachea was meticulously dissected and separated from the esophagus.

Under simultaneous bronchoscopic guidance, the lesion was accurately localized. The trachea was incised 1 cm proximal to the tumor using endoscopic scissors, followed by distal transection with adequate oncological margins. Posterior wall anastomosis was completed using 3-0 Prolene sutures. Cross-field ventilation was established thoracoscopically, enabling the completion of the anterior anastomosis. Afterward, the patient was successfully weaned from cross ventilation. The patient was extubated intraoperatively and transferred to the intensive care unit for postoperative monitoring. Anastomotic integrity was confirmed, and the suture line was reinforced with a pericardial fat pad.

The postoperative course was uneventful. Bronchoscopic evaluation on postoperative day three confirmed a patent airway and an intact anastomosis. The chest drains were removed on postoperative day three, and the patient was discharged on postoperative day seven without complications. Follow-up imaging demonstrated complete lung expansion with no evidence of residual pneumothorax or airway stenosis. Clinical follow-up at three and six months showed no evidence of recurrence.

Thus, this case highlights the feasibility of a uniportal non-intubated approach for distal tracheal resection, offering reduced airway manipulation and potential perioperative benefits. Careful patient selection, meticulous surgical technique, and coordinated bronchoscopic guidance are essential to ensure safe anastomosis and optimal outcomes (2).

References

1. Elktaibi A, Elhammoumi M, Boudhas A, Arsalane A, Eloueriachi F, Oukabli M, et al. Adenoid cystic carcinoma of the trachea: a clinico-pathological analysis. Pan Afr Med J. 2015;20:240.
2. Wang P, Wang Q, Zhang W, Zheng H, Zhao J. A simple and practical intraoperative ventilation technique for uniportal video-assisted thoracoscopic tracheal reconstruction: a case report. Ann Transl Med. 2022;10(9):529.

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