Tubeless tracheal resection and reconstruction for management of benign stenosis.

BACKGROUND: We reported a tubeless tracheal resection and reconstruction for the management of benign posttracheostomy tracheal stenosis. METHODS: A 34-year-old man with stridor, severe respiratory distress, and recurrent pneumonia was referred to our attention for treatment of benign posttracheostomy tracheal stenosis. As he refused general anesthesia, the procedure was performed while he was under local anesthesia and spontaneous ventilation. RESULTS: Sedation was started with infusion of dexmedetomidine 0.7 mg/kg/min and of remifentanil 0.5 mg/kg/h; also, 40%-50% oxygen was delivered using a laryngeal mask at a rate of 3.5 mL/min. An additional dose of 2% lidocaine was injected into the surgical site during the operation to achieve an adequate level of anesthesia. A standard resection and reconstruction of trachea was carried out and no recurrence was found in the follow-up of 41 months. CONCLUSION: Tubeless tracheal surgery seems to be a feasible and safe procedure. Larger prospective series should validate our results.

The effects of hyperbaric oxygen treatment on the healing of tracheal anastomosis following irradiation in rats.

BACKGROUND: After tracheal resection and end-to-end anastomosis, granulation tissue formation and stenosis along the anastomotic line are major problems. This experimental study in rats evaluated the effects of hyperbaric oxygen therapy on the healing of tracheal anastomosis after irradiation. METHODS: Forty-four rats were divided into four groups: Group I (n = 12) underwent tracheal anastomosis after irradiation (30 Gy) and received hyperbaric oxygen treatment; Group II (n = 12) underwent tracheal anastomosis and received hyperbaric oxygen treatment; Group III (n = 11) underwent tracheal anastomosis after irradiation (30 Gy); and Group IV (n = 9) underwent only tracheal anastomosis. Hyperbaric oxygen treatment was administered at 2.5 atmospheres of absolute pressure once a day for 1 week. The rats were sacrificed 28 days after tracheal anastomosis. The cross-sectional area (CSA) of the tracheal lumen was compared between groups. Inflammation, fibrosis, epithelization, alveolar congestion and alveolar hemorrhage were evaluated by histological analysis. RESULTS: The rats in all groups survived the study period, except for two in Group III which died from anastomotic dehiscence. Macroscopically, rats in the hyperbaric oxygen therapy groups showed excellent healing at the anastomosis. In these groups, CSA scores and epithelization were higher than in the other groups. There was local necrosis at the anastomosis in 3 rats in Group III. Fibrosis and alveolar congestion observed in Groups III and IV were significantly higher than in Groups I and II. CONCLUSION: This study suggests that hyperbaric oxygen treatment contributes to the healing of tracheal anastomosis following irradiation and may be a useful supportive treatment after tracheal resection and end-to-end anastomosis.

The effect of maternal betamethasone and fetal tracheal occlusion on pulmonary vascular morphometry in fetal rabbits with surgically induced diaphragmatic hernia: a placebo controlled morphologic study.

OBJECTIVES: We studied the vascular effects of betamethasone (BM) and/or tracheal occlusion (TO) in fetal rabbits with surgically induced congenital diaphragmatic hernia (CDH). METHODS: At day 23 (pseudoglandular phase; term = 31 d), 54 ovarian-end fetuses from 27 does underwent induction of CDH. Thirteen did receive either 0.05 mg/kg BM, on days 28 and 29 with a 24-h interval, or 14 saline [controls (CTR)]. At day 28, one ovarian-end fetus underwent TO and harvesting was at term. In total, we compared (ANOVA) lung-to-body weight ratio (LBWR) and vascular morphometric indices in survivors from the following groups (n - number alive at delivery): CDH (9); CDH + TO (10); unoperated controls (14); CDH + BM (10); CDH + TO (9); controls CTR + BM (13). RESULTS: Maternal BM had no effect on LBWR. LBWR was comparable to normal in CDH fetuses undergoing TO. Both TO and BM have an effect on medial thickening due to CDH which is larger when both interventions are combined. CONCLUSIONS: Both TO and BM lessen peripheric muscularization present in CDH lungs and their effect is cumulative.

Interventional bronchoscopy for treatment of tracheal obstruction secondary to benign or malignant thyroid disease.

STUDY OBJECTIVES: Surgery is the treatment of choice for symptomatic tracheal obstruction due to benign or malignant thyroid disease. In case of inoperability, or when surgery is refused, few therapeutic alternatives are available. Interventional bronchoscopic procedures have only been reported anecdotally. The objective of this study is to evaluate the results of interventional bronchoscopic procedures in the treatment of severe tracheal obstruction due to thyroid disease. STUDY DESIGN: Retrospective cohort analysis. SETTING: University hospital, tertiary referral center. PATIENTS: Thirty consecutive patients referred for bronchoscopic treatment of benign (n = 17) or malignant (n = 13) thyroid-related upper airway obstruction due to tracheomalacia, extrinsic compression, and/or tracheal ingrowth. Indications for bronchoscopic treatment were medical or surgical inoperability, prevention or treatment of tracheomalacia, and refusal of surgery. There were no procedure-related complications. INTERVENTIONS: Rigid bronchoscopy with dilatation, stenting and/or Nd-YAG laser treatment, and clinical follow-up. MEASUREMENTS AND RESULTS: Subjective improvement, pulmonary function tests, early and late complications, and survival. In the benign group, immediate (100% relief of dyspnea) and long-term (88% relief of dyspnea) results were excellent after airway stenting (21 stents used in 17 patients). There was one unrelated death 1 week after stenting in a 98-year-old patient. There were 6% and 30% short-term and long-term complications, respectively, that could be managed endoscopically. In the malignant group, Nd-YAG laser treatment (n = 3) and stenting (n = 13) yielded immediate and long-term success in 92% of patients. There were 15% short-term and 8% long-term complications. Median survival time was 540 days. CONCLUSIONS: Interventional bronchoscopic procedures including Nd-YAG laser treatment and stenting are valuable alternatives to surgery in inoperable thyroid-induced tracheal obstruction, or when surgery is refused.

Healing of a free tracheal autograft is enhanced by topical vascular endothelial growth factor in an experimental rabbit model.

OBJECTIVE: In 1996, we introduced the free tracheal autograft technique for repair of congenital tracheal stenosis from complete tracheal rings in infants and children. Sources of possible concern with this procedure include the potential for autograft ischemia, patch dehiscence, and recurrent stenosis. Vascular endothelial growth factor is a potent angiogenic inducer (particularly in the setting of ischemia, hypoxia, or both) and is postulated to promote tissue healing. The purpose of this study was to test the hypothesis that pretreatment of tracheal autografts with topical vascular endothelial growth factor would enhance tracheal healing. METHODS: In a rabbit model of tracheal reconstruction (n = 32), an elliptically shaped portion of the anterior tracheal wall was excised. The excised portion of trachea was one third of the tracheal circumference and 2 cm in length (6 tracheal rings). This portion of trachea (the autograft) was soaked in either vascular endothelial growth factor (5 microg/mL, n = 16) or normal saline solution (n = 16) for 15 minutes before being reimplanted in the resultant tracheal opening. Animals were killed and autografts were examined at 2 weeks, 1 month, and 2 months postoperatively for gross and microscopic characteristics. RESULTS: By 2 weeks, and progressing through 1 and 2 months, autografts treated with vascular endothelial growth factor, as compared with control autografts, had reduced luminal stenosis, submucosal fibrosis, and inflammatory infiltrate (P <.05). The autografts tended to become malaligned in control animals, whereas the tracheal architecture was preserved in rabbits treated with vascular endothelial growth factor. Microvascular vessel density was significantly greater in all vascular endothelial growth factor groups (P <.05) at all time intervals. CONCLUSIONS: Topical treatment of free tracheal autografts with vascular endothelial growth factor in a rabbit tracheal reconstruction model enhanced healing, as evidenced by accelerated autograft revascularization, reduced submucosal fibrosis and inflammation, and preservation of the normal tracheal architecture. Topical vascular endothelial growth factor may improve future results of tracheal reconstruction.

[Hydromassage of wound surface of surgically reconstructed laryngeal lumen and upper trachea]. / "Gidromassazh" ranevoi poverkhnosti vosstanavlivaemogo khirurgichskim putem prosveta gortani i verkhnei chasti trakhei.

In surgical reconstruction of laryngostenosis and stenosis of the upper trachea after dissection of the scars we place laryngotracheal prosthesis (LTP) in the created lumen for a year and longer. The LTP dilator prevents regrowing the scars into the larynx and trachea until termination of the wound epithelization. The author has designed a device which provides a pulsed change in the pressure of water-filled latex balloon-dilator of the LTP. This pulsed work is realized by 7-8-s sucking out water and filling again of 1/3 of water volume in the dilator. Such procedures lasting for 20-30 min conducted 2 times a day are called hydromassage of the larynx and trachea. In 7 patients subjected to hydromassage for a full time of wearing the LTP, epithelization of the wound surface of the reconstructed part of the airways occurred within 2-2.5 months. If hydromassage was performed for half the time of LTP wearing (12 patients) epithelization occurred within 3-3.5 months.

Intraoperative radiation therapy, endotracheal hyperthermia and IR-192-brachytherapy in patients with advanced thyroid cancer.

Tracheal stenosis due to infiltrative nonresectable thyroid cancer causes severe reduction in life quality. Palliative therapy, apart from tracheostomy is--up to now--intraluminal and/or external radiation. Good tumor control is achieved by local hyperthermia. A combined modality treatment (CMT) consisting of surgery, brachytherapy and intraoperative radiation, eventually combined with intraluminal NdYg-Laser-desobliteration was performed. An intraoperative radiation therapy (IORT)-protocol was designed for poorly differentiated non-anaplastic thyroid carcinoma. Out of 155 cases of differentiated thyroid tumors, 12 showed marked vascular and/or capsular invasion. Five entered the study (3 primarily local invasive tumors, 2 local recurring). IORT was administered after tumor surgery (4-10 Gy) and combined with postoperative percutaneous irradiation. The tumor control rate in the thyroid bed is 5/5, 1/5 developed mediastinal nodes, 1/5 with primary mediastinal tumor extend shows tumor progression. No specific complications occurred.

Congenital tracheal stenosis in lambs induced by maternal ingestion of Veratrum californicum.

Seven of nine lambs born to six ewes gavaged with Veratum californicum root and rhizome material on days 31, 32 and 33 of gestation died from asphyxia within 5 minutes after birth. Five of the seven were autopsied and found to have severe stenosis of the trachea. None of the 12 lambs born to seven control ewes had tracheal stenosis. The defect was characterized by lateral flattening of the trachea throughout its entire length. Cartilaginous tracheal rings were reduced in number, nonuniform in size and shape, irregularly spaced, and with abnormal orientation. The rings were thinner than those of control tracheas, and had zones of chondrogenesis on outer and inner surfaces which were of equal width, rather than of unequal width as in controls. The smaller size and relatively noncurved shape of the cartilaginous rings of the stenotic trachea resulted in a nondistended lumen.