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EDITORIAL
Year : 2012  |  Volume : 2  |  Issue : 1  |  Page : 3-4

On the TENSION in segmental tracheal resection


Department of Laryngology Bronchoesophagology, University of Alabama, Birmingham, United Kingdom

Date of Web Publication9-Apr-2012

Correspondence Address:
Paul F Castellanos
Department of Laryngology Bronchoesophagology, University of Alabama, Birmingham
United Kingdom
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/2230-9748.94726

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How to cite this article:
Castellanos PF. On the TENSION in segmental tracheal resection. J Laryngol Voice 2012;2:3-4

How to cite this URL:
Castellanos PF. On the TENSION in segmental tracheal resection. J Laryngol Voice [serial online] 2012 [cited 2021 Sep 25];2:3-4. Available from: https://www.laryngologyandvoice.org/text.asp?2012/2/1/3/94726

Segmental tracheal resection (STR) is a tried and true method to treat the worst of airway problems in the form of stenosis that is not amenable to dilation and debridement, or transoral and open tracheoplasty. [1] The risks of doing this surgery are few in number but great in consequence. This is the only operation I perform where I feel compelled to inform my patients (and their families) that perioperative death is a possibility. Thankfully, that has never happened in my own practice but, all comers, all surgeons, a risk of between 1 and 5% is commonly quoted. So why do this operation? Why subject the patient and family through the strain of facing such a dire outcome? After all, the patient is alive, sitting before you with a tracheostomy through which they are at present breathing well. The plain and simple answer is because we can. This is not a glib response. If you are a surgeon capable of performing this operation well, you are compelled to offer it to such patients when minimally invasive and less dangerous options have been exhausted. Admittedly, the potential for getting other operations to work for such unfortunate people can be a very long list of procedures including lasering and open reconstructions that do, in many cases, suffice. Unfortunately, some operations "consume" valuable normal airway in the process, making the, perhaps inevitable, STR even harder and more dangerous. So why avoid this Gold Standard in the realm of airway repair?

I will answer my own question. The hazards of STR begin with dehiscence of the anastomosis and end with recurrence of the stenosis. The two are linked because the airway surgeon, wanting to avoid a dehiscence, may accept a less than perfect airway to use in the closure. While there are certainly other risks to this operation such as unilateral or, worse, bilateral recurrent laryngeal nerve injury, this is surprisingly very rare. While there are many ways to avoid dehiscence, they increase the incidence of other problems such as postoperative dysphagia. Certainly, if a suprahyoid release and an inferior constrictor release have both been used, the patient has a much higher chance of being dysphagic. A deep pretracheal, intrathoracic dissection to allow the distal airway to come up under less tension has two big issues to consider: one, that the dissection itself will compromise the quasi axial blood supply and potentially generate a state of iatrogenic tracheomalacia. Worse, vascular insufficiency may cause necrosis of the distal stump and result in the breakdown of the anastomosis. The second is the risks associated with great vessel injury. The ineptly named Innominate Artery is easy to identify, but at times hard to dissect off of the pretracheal space because of the fibrosis that can occurs post-tracheotomy. The risk of injury to this vessel makes this dissection worth reconsidering. Well, if high dissection is promoting of iatrogenic dysphagia, and low dissection, of airway injury or worse, what is the solution? In my opinion, resection to a clear edge of mucosa proximally and distally should be the unwavering first commitment of the airway surgeon. An anastomosis containing the scar that provoked the STR in the first place is a bad approach, indeed. The second fundamental principle of STR is to provide for a low-tension suture line. This is the answer but not the "solution." This is the basis of all of the freeing-up techniques, here mentioned which are not sufficient solutions because of the problems that can follow such efforts. The alternative is, by some other means, to draw the bound tissues together such that the suture line is rendered tension free. The strain is some other way relieved. Enter the Laryngosternopexy. This technique, described on the web and soon in print, will in fact tether the larynx to the sternum, hence the name. Suture line tension can largely be neutralized and, perhaps more importantly, the risks of inadvertent extension with the potential for a sudden shearing of the anastomosis, largely obviated. Using this technique over the last decade, I have been able to remove rather long segments of the trachea, often more than half, without the need for cervical collars or, without the need for the chin-to-chest suture, known as the Grillo-Stitch (named for the great airway surgeon, Professor Hermes Grillo, who passed away 4 years ago). [2]

So, the tension in STR is the defining feature of the operation both in how one performs it and how one anticipates problems once it is complete. If you want to do this operation with as little tension in both spheres as possible, you either take your dissections far and wide, with the resultant risks, or you pexy the larynx to the sternum and be done with the whole problem. Do so and you will sleep as comfortably as your patients who can now breath through their mouth, perhaps for the first time in years. You will both be grateful.

 
   References Top

1.Pinsonneault C, Fortier J, Donati F. Tracheal resection and reconstruction. Can J Anaesth 1999;46:439-55.  Back to cited text no. 1
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2.Grillo HC. Surgery of the Trachea and Bronchi. Ontario: BC Decker Inc.; 2004. p. 539  Back to cited text no. 2
    

 
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