4/24/2017. Tracheal Stenosis. Tracheal Stenosis. Tracheal Stenosis. Tracheal Stenosis. Tracheal Stenosis Endoscopic & Surgical Management

Transcription

1 Endoscopic & Surgical Management Pressure ulceration Healing: granulation cicatrization contraction Ann Surg 1969;169: Gary Schwartz, MD Department of Thoracic Surgery and Lung Transplantation Baylor University Medical Center No disclosures Simple vs. complex / web-like Location glottic subglottic cervical trachea mediastinal trachea Extent Cotton s Classification I: < 70% II: 70%-90% III: > 90% IV: complete obstruction 1

2 Montgomery WW. T-Tube Tracheal Stent. Arch Otolaryngol 1965 Sep; 82: Rigid bronchoscopy Flexible bronchoscopy w/ balloon dilation Dumon JF. A dedicated tracheobronchial stent. Chest 1990;97:

3 Complications (5-15%): Migration Granulation Stent Fracture Mucous plugging Patient intolerance Respiratory infections A 47 year-old female has a metallic tracheal stent implanted for posttracheostomy tracheal stenosis. Regarding patients with tracheal stents: (a) Anti-platelet therapy is required for metallic stents but not silicone stents (b) Should only be intubated by awake, fiber-optic intubation (c) Do not require knowledge of exact stent location prior to attempted intubation (d) Typically require repeated interventions for long-term efficacy A 47 year-old female has a metallic tracheal stent implanted for posttracheostomy tracheal stenosis. Regarding patients with tracheal stents: (a) Anti-platelet therapy is required for metallic stents but not silicone stents (b) Should only be intubated by awake, fiber-optic intubation (c) Do not require knowledge of exact stent location prior to attempted intubation (d) Typically require repeated interventions for long-term efficacy 3

4 Manual debridement / debulking Electrocautery, argon Cryotherapy Laser ablation (CO 2, ndyag) Photodynamic therapy Future potential: Biodegradable absorbable Polydioxanone Drug-eluting Mitomycin, Cisplatin Custom-made Acrylic SILMET : selfexpanding nitinol stent made of nitinol 3-D printing 4

5 Surgical planning Cervical incision upper vs. full sternotomy, right thoracotomy 2-3 cm / 4-6 rings safely resected and primarily anastomosed Release maneuvers: annular ligament, suprahyoid, infrahyoid, intrathoracic tracheal, inferior pulmonary ligament The preferred method of ventilation during tracheal resection is: (a) Transtracheal jet ventilation (b) Cross table ventilation (b) Extracorporeal membrane oxygenation (c) Cardiopulmonary bypass The preferred method of ventilation during tracheal resection is: (a) Transtracheal jet ventilation (b) Cross table ventilation (b) Extracorporeal membrane oxygenation (c) Cardiopulmonary bypass 5

6 503 pts, 521 resections (residual + restenoses) Mean tracheal resection length 3.3 cm Outcomes measures: Good: normal daily activities, intact bronchoscopic airway Satisfactory: normal daily activities but exercise stress, bronchoscopic vocal cord issues or stenosis Failure: tracheostomy Failure rate: Tracheo-tracheal anastomosis 2.2% Crico-tracheal and thyrotracheal: 6-8% Mortality 2.4% End-stage tracheal stenosis is amenable to tracheal replacement utilizing a: (a) Human allograft trachea (b) Synthetic, non-viable tissue (c) Tissue-engineered trachea (d) Autogenous tissue transfer (e) None of the above 6

7 End-stage tracheal stenosis is amenable to tracheal replacement utilizing a: (a) Human allograft trachea (b) Synthetic, non-viable tissue Nonviable tissue (c) Tissue-engineered trachea (d) Autogenous tissue transfer (e) None of the above Foreign material Nonviable tissue Nonviable tissue Autogenous tissue Tissue engineering Transplantation Foreign material Autogenous tissue 1950 Oct;38(150):

8 Autogenous tissue Transplantation Tissue engineering Questions? Transplantation 8