Salvage tracheal reconstruction after failed endoscopic or surgical intervention

Henning A. Gaissert, Camilla Vanni, Maria Lucia L. Madariaga

Abstract

Tracheal reconstruction in the presence of shortened organ length and additional constraints after failed initial surgical or endoscopic intervention are rarely reported, and the conditions for success are hardly ever analyzed. Individual patients undergoing secondary tracheal reconstruction by one surgeon are described and illustrated with radiographs, endoscopic video and audio files. Four patients underwent second reconstructive tracheal attempts for postintubation injury in 2 patients, after resection of adenoid cystic carcinoma in 1 and of esophageal granular cell tumor in 1. Two patients presented with iatrogenic esophageal airway fistulas, in one following placement of a self-expanding metal stent. The surgical approach consisted of a cervical incision in 3 patients, for 1 of whom the operation was the second part of two stages, and a cervicomediastinal approach in an additional patient. The principal cause of failure was incomplete mobilization, inappropriate use of a tracheal stent, misjudgment of anastomotic tension and inappropriately radical tumor resection, respectively. After secondary reconstruction, all patients were free of airway tubes without additional recurrent laryngeal injury. First reconstructive failures before successful, second tracheal reconstruction occur because of avoidable errors in judgment or technique. First tracheal reconstructions require careful planning to reduce avoidable error. Second reconstructions may succeed when adequate residual tracheal length remains. Both demand precise surgical technique.