Key Points

• Complications after tracheal resection are uncommon, but are associated with significant morbidity and mortality.
• Patient selection, technical expertise and the right timing are crucial to avoid complications
• Patient-related risk factors for anastomotic complications are reoperation, diabetes, lengthy resections, laryngotracheal resections, and need for a tracheostomy before operation.
• Meticulous surgical dissection, tension-free anastomosis and healthy mucosa at the resection margins are surgical cornerstones to prevent anastomotic complications
• Complication management after airway surgery depends on the correct judgement of the situation and ranges from a wait-and-see strategy to immediate surgical intervention

Complications after airway surgery are relatively uncommon but can be life-threatening if related to the anastomosis because an adequate airway is essential. General medical complications are uncommon after airway surgery and are not addressed here. Complications are, of course, best avoided; hence, the proper planning and execution of an airway resection and reconstruction represent major steps toward avoiding trouble. Airway resection is almost never an emergency, so the surgeon can carefully evaluate the patient, consult as needed, prepare the patient for operation, and assemble an optimal operating team, including anesthesia. The one exception is a tracheoinnominate fistula (TIF) in which the airway is so damaged that it requires resection. A tracheoesophageal fistula (TEF) can almost always be temporized with a well-placed occlusive tracheostomy tube beyond the fistula. Airway obstruction can almost always be managed with bronchoscopy and dilation (for stenosis) or core-out (for tumor), converting an emergency to an elective eventual resection.

Patients with tumors are easier to judge in terms of their candidacy for resection, with the length of potential resection obtained from a combination of bronchoscopic and computed tomographic (CT) measurements. The remaining trachea usually has both a normal structural integrity and mucosa, which facilitates normal healing. Patients with stenosis are more difficult to judge because the length of resection required is more difficult to ascertain due to what is invariably a gradation of injury to the mucosa and the underlying cartilaginous structure of the trachea. Invariably, more trachea is resected than was originally thought to be necessary. Malacic segments (especially around tracheostomy stomas) are identified to the best extent possible preoperatively because they are often unreliable as an airway if anastomosed rather than resected.