Feedback

Complications of Airway Surgery

Cameron D. Wright
Complications of Airway Surgery is a topic covered in the Pearson's General Thoracic.

To view the entire topic, please or .

STS Cardiothoracic Surgery E-Book from The Society of Thoracic Surgeons provides expert guidance for Cardiac and Thoracic Surgery. Sections include Pearson’s General Thoracic, Esphageal, Adult Cardiac, and Pediatric and Congenital Cardiac Surgery. Explore these free sample topics:

-- The first section of this topic is shown below --

Key Points

  • Complications after tracheal resection are uncommon.
  • It is important to diagnose anastomotic complications early, to avoid loss of the airway or development of a fistula to the esophagus or innominate artery.
  • Any airway symptoms early after resection need to be investigated with bronchoscopy.
  • Risk factors for anastomotic complications are reoperation, diabetes, lengthy resections, age younger than 17 years, laryngotracheal resections, and need for a tracheostomy before operation.
  • Most anastomotic complications can be satisfactorily treated by reoperation, placement of a T tube, or tracheostomy.
  • Anastomotic complications markedly increase the risk of death after tracheal resection.
  • Laryngeal complications (edema, injury to the RLN, and swallowing dysfunction) are uncommon, rarely lead to major reintervention, and typically improve over a period of several months.

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 have an optimal operating team. 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 and there 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.

Patients receiving therapeutic doses of steroids are weaned off of them before resection. Steroids impair wound healing and defense against infection, so their use before a resection makes little sense. Their use to reduce so-called edema makes little sense as well; if a patient has a marginal airway, the best temporizing treatment is usually a bronchoscopic intervention. Radiation is another factor my colleagues and I prefer to avoid before operation because it impairs wound healing. One of the cardinal rules of surgery is broken after every tracheal resection (avoidance of tension on an anastomosis) and to some extent tension impairs healing. Therefore, it makes little sense to further impair adequate healing with preoperative irradiation. We do not use induction therapy for marginally resectable tumors. If we think the tumor might be resectable, we resect it; if there are microscopically positive margins, we treat postoperatively.

-- To view the remaining sections of this topic, please or --

Key Points

  • Complications after tracheal resection are uncommon.
  • It is important to diagnose anastomotic complications early, to avoid loss of the airway or development of a fistula to the esophagus or innominate artery.
  • Any airway symptoms early after resection need to be investigated with bronchoscopy.
  • Risk factors for anastomotic complications are reoperation, diabetes, lengthy resections, age younger than 17 years, laryngotracheal resections, and need for a tracheostomy before operation.
  • Most anastomotic complications can be satisfactorily treated by reoperation, placement of a T tube, or tracheostomy.
  • Anastomotic complications markedly increase the risk of death after tracheal resection.
  • Laryngeal complications (edema, injury to the RLN, and swallowing dysfunction) are uncommon, rarely lead to major reintervention, and typically improve over a period of several months.

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 have an optimal operating team. 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 and there 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.

Patients receiving therapeutic doses of steroids are weaned off of them before resection. Steroids impair wound healing and defense against infection, so their use before a resection makes little sense. Their use to reduce so-called edema makes little sense as well; if a patient has a marginal airway, the best temporizing treatment is usually a bronchoscopic intervention. Radiation is another factor my colleagues and I prefer to avoid before operation because it impairs wound healing. One of the cardinal rules of surgery is broken after every tracheal resection (avoidance of tension on an anastomosis) and to some extent tension impairs healing. Therefore, it makes little sense to further impair adequate healing with preoperative irradiation. We do not use induction therapy for marginally resectable tumors. If we think the tumor might be resectable, we resect it; if there are microscopically positive margins, we treat postoperatively.

There's more to see -- the rest of this entry is available only to subscribers.

Last updated: April 21, 2020