Chest Surg Clin N Am

13 (2003) 385 397

Management of complications
of tracheal surgery
Michael Lanuti, MDa,b,*, Douglas J. Mathisen, MDa,b
a

Massachusetts General Hospital, Blake 1570, 55 Fruit Street,

Boston, MA 02114, USA
b
Harvard Medical School, 25 Shattuck Street, Boston, MA 02115, USA

Post-intubation tracheal injuries remain the most common indication for

tracheal resection and reconstruction [1,2]. Meticulous attention to the details of
intubation, the technique of tracheostomy, and postoperative care can avoid the
development of complications of tracheal stenosis. Injury to the tracheal mucosa
during intubation might predispose patients to the development of stenosis. Proper
selection of tube sizes is essential for the prevention of laryngeal injury and injury
to the subglottic area. Ischemic injury to the mucosa or the larynx or subglottis from
overly large endotracheal tubes occurs more commonly in women, who tend to
have smaller larynxes than men. Despite low-pressure tracheostomy cuffs, overinflation of endotracheal and tracheostomy cuffs might lead to injury and tracheal
stenosis. Overinflation of low-pressure cuffs is responsible for a large number of
tracheal stenoses. It is important to avoid excessive tension on tracheostomy tubes;
excessive tension leads to excessive destruction of tracheal cartilages, increasing
the likelihood of a stomal stenosis after removal of the tracheostomy tube. If
another tracheotomy is needed to control the airway, it is imperative that the
tracheostomy be placed through the most damaged portion of the trachea, thus
preserving as much viable trachea as possible for future reconstruction.

High-risk patients
There are certain circumstances that place patients at high risk for complications
following tracheal resection and reconstruction. One of the most critical factors
influencing the success of tracheal surgery is the absence of need for mechanical
ventilation. The need for mechanical ventilation must be considered in high-risk

* Corresponding author. Michael Lanuti, MD, Massachusetts General Hospital, Blake 1570, 55
Fruit Street, Boston, MA 02114.
E-mail address: mlanuti@partners.org (M. Lanuti).
1052-3359/03/$ see front matter D 2003, Elsevier Inc. All rights reserved.
doi:10.1016/S1052-3359(03)00007-3

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groups such as quadriplegics and those affected by neuromuscular disorders

associated with weakness. Mechanical ventilation following tracheal resection
increases the risk of anastomotic complications and the possibility of dehiscence.
Many patients are mistakenly treated with high-dose steroids for presumed
adult-onset asthma. It is the authors belief that systemic steroids and some
degree of anastomotic tension are associated with a greater risk of anastomotic
dehiscence. It is therefore mandatory that patients be weaned from steroids before
any surgical intervention. It is often necessary to dilate strictures or remove tumor
bronchoscopically while steroids are being weaned.
Prior radiation therapy ( > 5000 cGy completed over 12 months before planned
resection) is also a relative contraindication. In certain highly selected patients,
tracheal resection and reconstruction can be performed using a well-vascularized
pedicle (eg, omentum) to encircle and buttress the anastomosis.
Another important variable in tracheal resection is the condition of the tracheal
mucosa. It is imperative that the tracheal mucosa be assessed. The presence of
inflammation related to the underlying disease or recent surgical procedure
(ie, tracheostomy, trauma, and laser) might dictate postponement of reconstruction until the process has subsided.
Before reconstruction, a careful assessment of the glottis should be obtained to
ensure an adequate glottic airway. It has been the authors practice to correct any
glottic abnormalities before tracheal reconstruction. Postintubation injuries must
be evaluated for tracheomalacia by way of awake flexible bronchoscopy or
fluoroscopy. Malacia might be observed either proximal or distal to an area of
stenosis, and it greatly influences the amount of trachea that is suitable for
reconstruction. Patients with known Wegeners granulomatosis and relapsing
polychondritis are extremely unpredictable and are best treated with palliative
measures rather than reconstruction.

Airway management
Management of critical airway stenosis can be a formidable challenge.
Understanding the principles of management might avoid ill-advised surgery
and minimize potential complications. Emergency tracheal resection should be
avoided. It is always preferable to stabilize the airway, properly evaluate the
patient, and perform resection under ideal circumstances. Upon initial presentation, simple measures such as cool humidified mist, bed rest, head elevation,
and cautious sedation are often helpful. As a substitute for oxygen, Heliox
(BOC Gases, Murray Hill, NJ) is often helpful in the acute setting. The lower
viscosity of Heliox is a great advantage in a stenotic airway. Any airway
manipulation under local anesthesiaespecially in the outpatient settingcould
precipitate airway obstruction from secretions, hemorrhage, or swelling. If intervention is necessary, postintubation stenosis can be safely dilated under general
anesthesia using dilators and rigid and flexible bronchoscopes [3]. The procedure is performed under direct visualization starting with a number 3.5 or 4 mm

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387

pediatric rigid bronchoscope, gradually increasing the size until a 7 or 8 mm

adult rigid bronchoscope can be gently passed through the stenosis. Tumors can
be cored out with biopsy forceps, rigid bronchoscopes, or with a laser.
Intervention in this manner can stabilize the airway from a few days to weeks
to allow further evaluation of a patients airway.
Acute airway distress can develop following tracheal resection and reconstruction in some patients. The etiology of this distress might be glottic edema,
inadequate airway following reconstruction, unrecognized glottic problems,
malacia, or vocal cord paralysis. If the need for an airway is anticipated at the
time of surgery, an uncuffed tracheostomy tube (#4 or #5) can be placed two rings
below the tracheal anastomosis with proper coverage of the suture line with local
tissues (eg, thyroid or cervical strap muscle). Alternatively, a small, uncuffed
endotracheal tube can be left in place and removed 2 to 3 days later in the
operating room with the patient under a light general anesthetic. If an inadequate
airway still exists, a small tracheostomy tube can be placed at that time.
Postoperative edema might compromise the airway. Edema of the larynx after
tracheal reconstruction is initially treated with fluid restriction, racemic epinephrine, and a brief course of systemic steroids (24 36 hours). If this treatment does
not resolve the problem, it is best to intubate the patient over a small, uncuffed
endotracheal tube. A brief period of time should be allowed for swelling to
subside, then the patient should be evaluated in the operating room for intubation
or tracheostomy as described previously.

Management of complications
Complications of tracheal resection and reconstruction vary with the pathologic
condition. As previously stated, the vast majority of operations are performed for
postintubation stenosis. Resection of tracheal neoplasms is the next most common
reconstruction performed. Reconstructions for infectious diseases, idiopathic
stenosis, traumatic lesions, congenital deformities, and extrinsic compression
present with special problems, but the general principles are the same.
For tumors, the tracheal mucosa is usually normal, whereas for postintubation
problems, the mucosa can have varying degrees of inflammation or fibrosis.
The most comprehensive account of complications following tracheal resection was reported by Grillo and colleagues in 1986 [4], and updated in 1990 for
resection of neoplasms [5] and for resection of postintubation stenosis in 1995
[6]. The results of this work form the basis of further discussions about
complications of tracheal resection.

Results
A total of 521 tracheal resections and reconstructions were performed on
503 patients. Thirteen patients had restenosis after an initial procedure and were

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reoperated at a later date. Five patients had immediate failure because of residual
tracheal malacia and were reoperated within hours of their initial procedure.
Evaluation of this cumulative patient series revealed a progressive increase
in the complication rate as the anastomotic level ascended. The failure rates were
2.2% for trachea trachea anastomosis, 6.0% for a trachea cricoid anastomosis,
and 8.1% for trachea thyroid anastomosis (Fig. 1). Minor complications became
more prevalent with each level, from 16% to 17.1% to 21%, respectively.
The major complication rate did not appear to change (13.9%, 15.4%, and
12.9%, respectively).
Complications can be divided into failures of incomplete diagnosis, failure of
technique, and those not easily classified. Failures of incomplete diagnosis, which
were limited largely to postintubation lesions, resulted from (1) failure to
recognize incompetence of the glottis before tracheal repair, and (2) failure to
recognize the extent of malacia present in addition to stenosis, a condition that
requires intervention at the initial operation. A third problem identified in patients
after prior operative failure was that the extent of stenosis had been unrecognized
with an inadequate resection.
The second group of complications contains failure of technique. Formation of
granulation tissue at the anastomosis must be classified as an error in technique
and in selection of patients. Separation of an anastomosis is (in most cases)
because of excessive tension caused by resection of too much trachea or failure to
perform relaxing maneuvers to lessen tension. Excessive circumferential dissection of the trachea, particularly distal to the point of division, might compromise
the blood supply and result in separation or stenosis. Excessive resection is more
likely to occur in the management of tumors. Partial or complete stenosis can
occur at the anastomotic line. This phenomenon results from granulation tissue
that gradually turns into cicatrizing circumferential scar or, more often, into
partial separation. The latter can occur without clinical air leak because of tension

Fig. 1. Categories of reconstruction. (a) Trachea to trachea anastomosis after segmental tracheal
resection. (b) Cricotracheal anastomosis where transaction is just below the cricoid cartilage, or where
a portion of lower cricoid cartilage, usually anterior, has been resected. (c) Anastomosis of tailored
trachea to thyroid cartilage or cricothyroid membrane anteriorly, where subglottic laryngeal
involvement by stenosis required laryngoplasty.

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389

Table 1
Complications of operations for postintubation tracheal stenosis

Granulations
(Before 1978)
(After 1978)
Dehiscence
Laryngeal dysfunction
Malacia
Hemorrhage
Edema (anastomotic)
Infection
Wound
Pulmonary
Myocardial infarction
TEF
Pneumothorax
Line infection
Atrial fibrillation
Deep venous thrombosis
Total

Major

Minor

Total

11
10
1
28
11
10
5
3

38
34
4
1
14
0
0
1

49
44
5
29
25
10
5
4

7
5
1
1
0
0
0
0
82

8
14
0
0
3
1
1
1
82

15
19
1
1
3
1
1
1
164

Data from Grillo HC, Donahue DM, Mathisen DJ, et al. Postintubation tracheal stenosis: treatment
and results. J Thorac Cardiovasc Surg 1995;109:486 93.

over time. Complications following resection for postintubation stenosis are

summarized in Table 1.
Granulations
In 49 patients, granulation tissue formed at the site of the tracheal anastomosis.
Only five such cases out of 317 (1.6%) have had the complication since 1978,
when the suture material used for anastomosis was changed from Tevdek
polyester [Deknatel (Genzyme Biosurgery Corporation, Fall River, MA)] to
Vicryl [Ethicon (Johnson & Johnson, Somerville, NJ)]. Before the change in
suture material, 44 of 186 patients (23.6%) developed granulation tissue at the
anastomosis. Thirty-eight of these 49 patients were managed by bronchoscopic
removal of granulation tissue. Of 11 patients with more complicated problems,
five required reoperation for a second resection and reconstruction; all had good
results. Four patients required tracheostomy, one of which was temporary, and
two patients were managed with T-tubes.
Dehiscence and restenosis
The most devastating complication following tracheal resection is dehiscence
or restenosis. This occurred in 29 patients. If dehiscence is suspected, the patient
must be taken immediately to the operating room for evaluation and stabilization
of the airway. Seven patients with this complication died; two also had innominate
artery erosion. Eight patients were managed with subsequent resection and
reconstruction, all with either good (N = 6) or satisfactory (N = 2) results. Four
patients required permanent tracheostomy. Five patients required a T-tube, three of

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which were temporary. Three patients had dehiscence of a small portion of the
anastomosis. Two of these patients required re-exploration and primary closure,
and one patient with a small leak was successfully managed with drainage of the
cervical wound and antibiotics. Two patients required repeated dilatations.
Laryngeal dysfunction
A total of 25 patients had varying degrees of laryngeal dysfunction after the
operation. Fourteen patients had minor or temporary dysfunction that prompted
no specific treatment. Eleven patients had more severe dysfunction. Of these,
seven patients required tracheostomy, four of which were temporary. One patient
required a permanent T-tube, and another required a subglottic stent. Two patients
required gastrostomy tube feedings for persistent aspiration resulting from glottic
dysfunction. One death occurred in this group.
Laryngeal complications, aspiration, or vocal cord dysfunction appeared in
four of nine patients undergoing thyrohyoid laryngeal release (44%) and in eight
of 40 patients (20%) undergoing suprahyoid release. Laryngotracheal resection
(trachea thyroid cartilage anastomosis) plus laryngeal release in eight patients
led to three minor and four major complications in six of the eight patients. These
complications included dysphagia, aspiration, malacia, and partial or complete
dehiscence in three patients.
Hemorrhage
Five patients hemorrhaged from the innominate artery. Three of these patients
died, two of whom had concomitant anastomotic separation. One patient was
managed successfully with repair of the artery, and one was managed with
division of the innominate artery.
Anastomotic edema
Four patients were noted to have swelling at their anastomoses. In one patient
the swelling was minor and treatment consisted of oral steroids. Two patients
were treated with temporary tracheostomy, and one patient was treated with a
temporary T-tube.
Infection
Infectious complications developed in 34 patients. Wound infection accounted
for 15 of these cases. Eight minor infections were treated with intravenous
antibiotics and seven more extensive sternal infections required operative
debridement. Nineteen patients had bronchitis or pneumonia, 14 of whom
required intervention with bedside bronchoscopic treatment and antibiotics. Five
more severe cases resulted in one death. Three patients were managed with
temporary tracheostomy and two patients were managed with reintubation.
Tracheomalacia
Residual tracheomalacia was identified during or after the operation in
10 patients. There were two deaths in this group. Five patients required reopera-

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391

tion; four of these patients underwent a second resection and reconstruction and
one patient underwent plastic ring splinting of the malacic segment. Results of the
reoperations were good in two patients and satisfactory in two patients. The fifth
patient required permanent tracheostomy. Two patients were treated with a T-tube,
one of which was temporary. One patient required temporary tracheostomy.
Other
One postoperative myocardial infarction occurred, resulting in the patients
death. Three patients with postoperative pneumothorax were treated chest tube
thoracostomy. One of each of the following complications was seen: intravenous
line infection, deep venous thrombosis, atrial fibrillation, insulin reaction, and
aspiration through a T-tube, requiring conversion to tracheostomy.

Deaths
Twelve perioperative deaths occurred in this compilation of patients. Complications related to anastomotic dehiscence were the most common causes,
accounting for seven deaths. Only two patients were supported with ventilators at
the time of resection, and three patients required postoperative reintubation for
retained secretions. One patient had received mediastinal radiation therapy for
Hodgkins disease with subsequent paratracheal fibrosis and failure of anastomotic healing despite omental wrapping. Two patients had a tracheoinnominate
artery fistula after dehiscence. Two patients died of airway obstruction secondary
to residual tracheomalacia. There was one postoperative fatal myocardial infarction. One patient died at home from respiratory failure of unknown cause.
Experience plays a role in the incidence of complications (Table 2). In an
earlier report, Grillo [4] noted a reduction in the number of deaths, failures of
reconstruction, and number of complications in the second half of a personal
series of 279 patients operated upon for postintubation stenosis.
In contrast with the complications seen with resection and reconstruction for
postintubation stenosis, Grillo and Mathisen [5] reported their results for treatment
of primary tracheal neoplasms. The type and incidence of complications were
slightly different than following resection for postintubation stenosis. Anastomotic
stenosis developed in two patients who underwent tracheal resection, one of which
had a transient air leak. Both patients later underwent re-resection successfully, one
while receiving high-dose steroids. Stenoses developed in four patients after carinal
Table 2
Influence of experience on management of postintubation lesions
Case No.

Deaths
Failures
Complications

1 139

140 279

4
13
42

1
7
30

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resection. Two patients who had undergone pneumonectomy with carinal resection
underwent re-resection successfully. Two other patients required upper lobectomy
of the reimplanted right lung with reattachment of the bronchus intermedius or
lower lobe. Both procedures were successful. Three air leaks were handled conservatively. In the era before absorbable sutures were used, four patients developed
suture line granulomas, which were managed with bronchoscopic intervention.
One esophageal fistula occurred after transthoracic tracheal resection with extensive full-thickness resection of the esophageal wall. One small fistula healed
spontaneously. Vocal cord paralysis occurred in eight patients who underwent
tracheal or carinal resection for squamous carcinoma and in three patients who
underwent tracheal or carinal resection for adenoid cystic carcinoma. Six patients
experienced aspiration on swallowing, principally after laryngeal release prompted
by extended resection. Most occurrences of vocal cord paralysis resolved with
time; however, temporary gastrostomy was infrequently required. One patient had
a small empyema after transthoracic tracheal resection that was ultimately treated
with drainage.
In two patients, pulmonary edema developed acutely after carinal resection
with right pneumonectomy. Three other patients had pneumonia. One patient
developed hypoxemia after a carinal resection with anastomosis of the trachea to
the right mainstem bronchus and exclusion of the left lung. The left pulmonary
artery had not been ligated. This patient ultimately required a left pneumonectomy to remove the nonfunctioning but shunting lung.

Treatment and prevention of complications

Granulation tissue
Granulation tissue at the suture line results predominately from nonabsorbable
sutures. The granulation tissue should be removed and the offending suture extracted with biopsy forceps. Triamcinolone can be injected locally to impede the
reformation of granulations. Adoption of absorbable sutures for anastomosis (4-0
Vicryl) has virtually eliminated anastomotic granulations and some late restenosis.
Airway separation
Acute airway separation post tracheal reconstruction might first manifest as
subcutaneous emphysema. This finding demands bronchoscopy emergently and
re-exploration to identify tracheal dehiscence. Limited anastomotic separation
might be resutured if it occurs early and there is no necrosis from compromised
blood supply. The repair should then be buttressed with a well-vascularized
cervical muscle flap. If the tissues do not appear to be appropriate for resuturing,
a tracheostomy tube can be placed across the defect to be replaced later by a
silicone T-tube [7]. A T-tube can be placed initially if the patient does not require
a sealed airway.

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With partial restenosis, the resulting airway might be clinically tolerated and
sometimes might improve with endoscopic techniques, including laser. Severe
stenosis or recurring partial stenosis requires aggressive treatment because other
measures offer only temporary palliation. The stenotic area can be dilated and a
T-tube can be placed across it to temporize it. After an attempt at tracheal
reconstruction has failed, 4 to 6 months should be allowed to quell the inflammation before another resection is undertaken. The presence of a T-tube permits
the luxury of waiting while maintaining an adequate airway. The difficulties of
tracheal reconstruction increase markedly with each attempt at repair.
Stenosis
Ensuring a tension-free reconstruction can prevent stenosis of a tracheal
anastomosis. Furthermore, when proceeding with tracheal resection for postintubation stenosis, all of the trachea that is involved by severe inflammatory
stenosis must be removed to prevent recurrence at that site. On the other hand, it is
important not to resect so much trachea that there will be excessive tension at the
anastomosis, particularly in patients with tumors or with previously operated
stenotic lesions. Anastomotic tension is usually judged clinically. Adjunctive
maneuvers such as laryngeal and hilar release might be required. On occasion, it
is better to abort the operation after exploration of a trachea rather than perform
too lengthy a resection. Conservative management of postintubation lesions can
be accomplished with inlying silicone rubber T-tubes, and obstructions from a
tumor can be opened bronchoscopically and palliated with radiation.
Hemorrhage
Major hemorrhage, which is usually from the innominate artery, mandates immediate reoperation. If blood enters the airway, emergent placement of a
cuffed endotracheal tube can potentially seal the bleeding site while operative
plans are set in motion. The surgical approach is through a combination of collar
incision and median sternotomy. The innominate artery is controlled proximally
and distally and the fistulous segment is resected. Proximal and distal ends of the
artery are then closed with two layers of running vascular suture and the divided
ends are covered in healthy tissue such as thymus, omentum, or cervical muscle.
Simple ligation is not advised. If available, intraoperative electroencephalogram
monitoring can be used while the artery is clamped. If marked changes occur on
the electroencephalogram, an autologous saphenous vein graft should be used
with omentum generously wrapped around it to deal with local infection.
Neurologic sequelae are rare after division of the innominate artery in the
presence of a previously normal circulation.
Dissection behind the innominate artery should be performed on the trachea to
leave adjacent tissue undisturbed around the artery. This will prevent mostif not
allpostoperative hemorrhages from that artery. In reoperations, dense adherence
might be encountered between the innominate artery and the trachea. In such

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cases, healthy tissue such as pedicled cervical strap muscle can be interposed
between the trachea and the artery. Similarly, in the thorax, tissue must always be
interposed between the tracheobronchial suture lines and the pulmonary artery.
Malacia
Residual malacia is best treated by recognizing it during the original operation
and including it in the resection. If doing so would extend the resection excessively,
the trachea can be splinted either internally with a T-tube without resection, or
externally with plastic rings. Foreign material is avoided unless it is absolutely
necessary. Laryngeal release can potentially enable the length of resection to be
increased, permitting excision of adjacent malacia along with a stenosis.
Fistulae
Tracheoesophageal fistulae are rare complications of tracheal resection and
reconstruction. They should be repaired if encountered. If there are technical or
systemic reasons to delay repair, the fistula can usually be managed with a
tracheal T-tube or, sometimes, a cuffed tracheostomy tube. Gastrostomy is
implemented to avoid aspiration from reflux and jejunostomy for nutrition. The
fistula is repaired when local inflammation has subsided [8]. Repair can be
accomplished by simple division and closure of the fistula or by segmental
tracheal resection and primary anastomosis with esophageal closure. Diversion of
the esophageal contents from the tracheobronchial tree is rarely indicated.
Aspiration
Aspiration on deglutition is commonly seen early after thyrohyoid release of
the larynx and, less often, after suprahyoid release. The glottis might close
inadequately on swallowing when the trachea has been markedly shortened,
when there has been injury to one of the recurrent nerves, or when neurologic
injury is present. If there is no improvement after a prolonged period during
which the patient has been fed by gastrostomy, it might become necessary
to surgically close the glottis and resort to tracheostomy and an artificial
speech device.
Glottic problems
Glottic problems, including an inadequate aperture or inadequate closure that
permits aspiration, must be corrected before tracheal reconstruction is attempted.
Careful radiologic and endoscopic assessment of the state and function of the
glottis and subglottic area should therefore be ascertained preoperatively [9]. Of
equal importance is the evaluation of the presence or absence of malacia in
addition to a stenotic lesion and any disorders of deglutition. Consultation with a
specialized radiologist, otolaryngologist, pulmonary specialist, and anesthesiologist will avoid many complications that can lead to postoperative disasters.

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395

Patients should be selected, prepared, and managed intraoperatively in such a

fashion that they will rarely require postoperative intubation and ventilation.
Vocal cord paralysis
Vocal cord paralysis usually warrants a period of observation before any
intervention is undertaken. Over a period of 6 months to 1 year, the patients
voice might return. If not, otolaryngologic procedures including teflon injection of
the paralyzed cord can improve the situation. If obstruction results from bilateral
vocal cord paralysis, the patient requires urgent endotracheal intubation, tracheostomy, or a T-tube through the vocal cords. Procedures such as arytenoidectomy
or cord lateralization are then needed to provide an adequate glottic aperture.
Edema
Acute airway edema after tracheal reconstruction is immediately treated with
racemic epinephrine, head elevation, diuretics, and 24 hours of systemically
administered steroids. Local steroid injection has also been used concomitantly.
An uncuffed endotracheal tube might be required for 48 to 72 hours, followed by
detection of an endotracheal air leak. If edema persists beyond this period, a small
tracheostomy tube can be carefully placed away from the anastomotic suture line
and distant from the innominate artery. A tracheostomy tube is never placed
through a fresh anastomosis or so close as to infringe upon the healing of an
anastomosis. Edema is most likely to develop after a complex laryngotracheal
resection for subglottic stenosis involving the larynx.
Another potential therapy for acute airway edema after tracheal reconstruction is
the use of Heliox [10,11]. Helium has a density that is significantly lower than that
of air. A mixture of helium and oxygen, termed Heliox, has a lower density than
does a mixture of nitrogen and oxygen. Breathing Heliox leads to a reduction in
resistance to flow within the airways, and consequently to a decrease in the work of
breathing. These beneficial effects have been observed in patients with asthma,
chronic obstructive lung disease, bronchiolitis, bronchopulmonary dysplasia, and
upper airways obstruction [12]. The gas mixture might provide the time necessary
while awaiting the benefit of conservative maneuvers previously mentioned.
Stoma
A persistent stoma usually results when the stoma has been present for a long
time and has eroded to a large size. The cutaneous epithelium has usually become
adherent to the tracheal epithelium. Such stomas are often closed during the
initial tracheal reconstruction or closed secondarily at another setting.
Surgical resection for postintubation stenosis is almost never an emergency.
Only in patients with stenosis immediately above the carina (where airway control
is exceedingly difficult to maintain) or in the patient with hemorrhage from
tracheoinnominate fistula is emergent surgical intervention required. In almost all
other patients it is possible to dilate the stenosis endoscopically or through a

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Table 3
Postintubation lesions: results of treatment complications

Granulations
Separation
Restenosis
Malacia
Hemorrhage
Tracheoesophageal fistula
Cord dysfunction
Aspiration
Wound infection
Edema

No.

Good

Satisfactory

Failed

Death

28
4
21
3
2
1
5
1
6
1

24

6
1
1

4
2
15

1
1

1
1
1

tracheostomy. If necessary, one could intubate across the lesion with a tracheostomy tube or T-tube [13]. Long-armed T-tubes are available for low stenoses.
Patients on ventilators should almost never be subjected to tracheal reconstruction.
Table 3 summarizes the results of management of complications after resection
of postintubation lesions [5]. Separation, hemorrhage, and tracheoesophageal
fistula, although infrequently encountered, were the most dangerous, resulting in
four of the five deaths.

Summary
Basic principles of tracheal reconstruction, which were introduced in the
1960s and 1970s, served to reduce the prevalence of many complications. These
principles include thorough preoperative assessment (endoscopic and radiologic)
of the tracheal anatomy and glottic function, avoidance of excessive anastomotic
tension, preservation of tracheal blood supply, and meticulous dissection and
anastomosis. The tracheal surgeon should have access to expert help in radiology
and anesthesiology, experienced nursing units, and the help and advice of
consultants, especially otolaryngologists. The surgical approach should be
meticulously planned. No irreversible maneuvers should be performed until
one establishes certainty to proceed to resection. The surgeon should not attempt
to exceed the limits of what appears to be reasonably possible. It must be
remembered that a permanent tracheal T-tube might be the best solution for a
patient with extensive tracheal damage that would defy reconstruction.

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cuffed tubes: a pathologic study. Ann Surg 1969;169:334 48.
[3] Wilson RS. Anesthetic management for tracheal reconstruction. In: Grillo HC, Eschapasse H,

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