[Tracheal Surgery]. / Chirurgie der Trachea.

Surgery of the trachea is a specialised field in which many disciplines work jointly due to the variety of indications and the extended topography. Not only because of its particular functional importance, but also because of its complex morphology, anatomy and physiology, this organ represents a special therapeutic challenge. A variety of diseases require surgical procedures of the trachea; the therapeutic strategy is influenced both by the disease itself as well as patient-dependent parameters. Regardless of the nature of the underlying disorder, good results require a high level of expertise in airway management, a careful diagnosis and interventional planning as well as an experienced surgical team that masters extended operative techniques. An optimal treatment decision always requires a multidisciplinary assessment of the patient's individual situation by interventional pulmonologists, thoracic surgeons, visceral surgeons, ENT (ear, nose and throat) surgeons and anaesthesiologists.

[Failure of Endo-VAC or Stenting Therapy after Oesophageal Anastomotic Insufficiency - How to Avoid Oesophagectomy]. / Interdisziplinäres Management bei Anastomoseninsuffizienz nach Ösophagusresektion zur Vermeidung der Ösophagektomie.

INTRODUCTION: Oesophageal anastomotic leak after oesophagectomy is a severe complication and associated with a high mortality rate. Initial treatment is conservative and includes stent implantation or endo-VAC therapy. This study describes a combined treatment strategy of endoscopic and surgical management after failure of conservative management. MATERIALS AND METHODS: All patients were included who had been treated after oesophagectomy with gastric conduit reconstruction in our department of thoracic surgery between May 2008 and December 2016. Clinical data was evaluated from a prospectively acquired database. We surgically managed these patients with a combination of oesophageal stent implantation, transmural stent fixation with absorbable suture, stent coverage with muscle flap, radical debridement of mediastinal and pleural empyema and discontinuous pleural space irrigation, when conservative management failed. We evaluated the factors influencing mortality rate after surgical treatment of anastomotic insufficiency repair. RESULTS: 18 patients were introduced to our department after external failure of conservative therapy. 15 patients were introduced < 20 days after conservative therapy and three cases after > 20 days of conservative therapy. All patients presented with right sided pleural empyema, pneumonia, mediastinitis and sepsis. Three cases were accompanied by bilateral pleural empyema. Definitive successful surgical reconstruction occurred in 100%. The 90-day mortality rate was 20% (three patients), who died because of multi-organ failure. CONCLUSION: Oesophageal anastomotic leak after oesophagectomy can be managed successfully by the combined treatment strategy of endoscopic and surgical procedures following failure of conservative treatment. The only factor influencing mortality seems to be a prolonged conservative therapy of more than 20 days.

[Tracheal Surgery]. / Chirurgie der Trachea.

Surgery of the trachea is a specialised field in which many disciplines work jointly due to the variety of indications and the extended topography. Not only because of its particular functional importance, but also because of its complex morphology, anatomy and physiology, this organ represents a special therapeutic challenge. A variety of diseases require surgical procedures of the trachea; the therapeutic strategy is influenced both by the disease itself as well as patient-dependent parameters. Regardless of the nature of the underlying disorder, good results require a high level of expertise in airway management, a careful diagnosis and interventional planning as well as an experienced surgical team that masters extended operative techniques. An optimal treatment decision always requires a multidisciplinary assessment of the patient's individual situation by interventional pulmonologists, thoracic surgeons, visceral surgeons, ENT (ear, nose and throat) surgeons and anaesthesiologists.

Does less surgical trauma result in better outcome in management of iatrogenic tracheobronchial laceration?

BACKGROUND: Iatrogenic tracheobronchial injury is a rare, but severe complication of endotracheal intubation. Risk factors are emergency intubation, percutaneous dilatational tracheostomy and intubation with double lumen tube. Regarding these procedures, underlying patients often suffer from severe comorbidities. The aim of this study was to evaluate the results of a standardized treatment algorithm in a referral center with focus on the surgical approach. METHODS: Sixty-four patients with iatrogenic tracheal lesion were treated in our department by standardized management adopted to clinical findings between 2003 and 2019. Patients with superficial laceration were treated conservatively. In the case of transmural injury of the tracheal wall and necessity of mechanical ventilation, patients underwent surgery. We decided on a cervical surgical approach for lesions limited to the trachea. In case of involvement of a main bronchus we performed thoracotomy. Data were evaluated retrospectively. RESULTS: In 19 patients the tracheal lesion occurred in elective intubation and in 17 patients during emergency intubation. In 23 cases a tracheal tear occurred during percutaneous dilatational tracheostomy and in three patients at replacement of a tracheostomy tube. Two patients received laceration during bronchoscopy. Twenty-nine patients underwent surgery with cervical approach and 14 underwent thoracotomy. There was no difference in the mortality of these groups. Treatment of tracheal tear was successful in 62 individuals. Nine patients died of multi organ dysfunction syndrome (MODS), two of them during surgery. CONCLUSIONS: Iatrogenic tracheal laceration is a life-threatening complication and the mortality after tracheal injury is high, even in a specialized thoracic unit. Conservative management in patients with superficial tracheal lesion is a feasible procedure. In case of complete laceration of tracheal wall, surgical therapy is recommendable, whereby several approaches of surgical management seem to be equivalent.

Extended tracheal resections.

There is no universally valid definition of the extent of tracheal resections that would be considered "extended." Underlying disease, necessary length of resection, anatomic localization, and chosen surgical approach account for a manifold interdependency. Existing data suggest a "cutoff margin" of 4 cm or more, referring to the likelihood of complications and necessity of additional mobilization maneuvers. This overview outlines worldwide experiences and the surgical variety of possibilities, as well as their execution and appropriate use.