Role of endotracheal stenting in tracheal reconstruction surgery retrospective analysis q

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1 European Journal of Cardio-thoracic Surgery 25 (2004) Role of endotracheal stenting in tracheal reconstruction surgery retrospective analysis q Arpad Pereszlenyi a, *, Martin Igaz b, Ivan Majer c, Svetozar Harustiak a a Clinic of Thoracic Surgery, National Tuberculosis and Respiratory Diseases Institute, Krajinska Street No. 91, Bratislava, Podunajske Biskupice, Slovak Republic b Department of Pathology, Comenius University of Bratislava, Bratislava, Slovak Republic c Department of Bronchoscopy, National Tuberculosis and Respiratory Diseases Institute, Bratislava, Slovak Republic Received 13 October 2003; received in revised form 16 January 2004; accepted 16 February 2004 Abstract Objective: To review a single institution experience with tracheal stenosis treatment and to define a role of endotracheal stenting in tracheal reconstruction surgery. Patients and methods: In the period between January 1991 and January 2003, 163 patients underwent tracheal reconstruction. There were 114 males and 49 females in age range from 0.5 to 79 years (mean 43.2 years). Indications for reconstruction were: posttracheostomic (PostTS) and postintubation (PostINT) stenoses in 111 cases, tumor-stenosis in 24 cases, tracheoesophageal fistulas (T-Efist) in 17 cases, traumatic laesions in six and functional stenosis in five cases. For these indications, the following procedures were performed: segmental tracheal resection in 87 cases, stenting in 68 cases (by our own modification of Montgomery T-tube in 65 cases and by other traditional endo-stents in three cases). Primary suture of traumatic tracheal wall was performed in five cases. Three cases involved laser intervention and tumor resections, respectively. Results: Segmental tracheal resection ðn ¼ 87Þ was successful in almost all the cases (96%). T-tube was applied in 65 cases; the indications included: PostTS and PostINT stenoses in 38 cases, tumors in 17 cases, T-E fistulas in seven cases and functional stenosis in three cases. Twenty-seven patients (41.6%) were successfully treated by this modality. In 19 patients (29.2%), the stenting is still continuing, but they are candidates for extraction of the T-tube in near future. In 19 patients (29.2%) with malignant stenoses, the T-tube was applied only as a palliation. All these patients died due to their underlying malignant disease; the follow-up ranged from 2 to 18 months. Conclusion: Tracheal stenosis is a serious, life-threatening disease with increasing incidence. In our study, the best results were achieved by segmental tracheal resection. However, the endotracheal stenting is the method of choice, when the segmental resection cannot be performed. The management of tracheal stenosis reconstruction by our own modification of Montgomery T-tube is being presented. q 2004 Elsevier B.V. All rights reserved. Keywords: PostTS, Posttracheostomic tracheal stenosis; PostINT, Postintubation tracheal stenosis; T-Efist, Tracheo-esophageal fistula 1. Introduction Tracheal stenosis is a serious, life-threatening disease with an increasing tendency [1,2]. Despite applying the newest treatment procedures and using advanced materials, it still often resists any treatment management. The increased number of tracheal stenosis can be considered as today s tax for improved patients survival due to q Presented at the joint 17th Annual Meeting of the European Association for Cardio-thoracic Surgery and the 11th Annual Meeting of the European Society of Thoracic Surgeons, Vienna, Austria, October 12 15, * Corresponding author. Tel.: þ ; fax: þ address: arpad_pp@hotmail.com (A. Pereszlenyi). modern successful intensive care. This number mainly includes stenoses after long-term tracheal intubation and after tracheostomy intervention [3,4]. Management of obstructive tracheal laesion, which develops as a result of long-term intubation, is a complex problem, which requires individual approach. Fully developed stenotic laesion with a high degree of obstruction, which is manifested certain time later after extubation, requires radical surgical resection. As it is known, it is not always feasible [2,4]. The number of complicated tracheal laesions, where its resection and anastomosis are not successful or not applicable, increases and the situation requires solution by endoprosthesis [2,5,6]. Among the large number of endoprosthesis applicable for tracheal /$ - see front matter q 2004 Elsevier B.V. All rights reserved. doi: /j.ejcts

2 1060 A. Pereszlenyi et al. / European Journal of Cardio-thoracic Surgery 25 (2004) retrospective analysis focuses on these above-mentioned 65 patients (Table 1) T-tube Fig. 1. Indications for tracheal interventions. stenting a significant place belongs to the T shaped tubes [7,8]. The main goal of this paper is to review the single institution experience with tracheal stenosis treatment and to define a role of endotracheal stenting in tracheal reconstruction surgery. This paper presents retrospective analysis of tracheal stenosis reconstruction by a modified Montgomery T-tube invented in our Clinic. 2. Patients and methods 2.1. Patients demographics, indications for tracheal reconstruction In the period between January 1991 and January 2003, 163 patients underwent tracheal reconstruction in our Clinic of Thoracic Surgery in National Tuberculosis and Respiratory Diseases Institute, Bratislava, Slovak Republic. There were 114 males and 49 females in age range from 0.5 to 79 year (mean 43.2 years). Indications for reconstruction were: posttracheostomic (PostTS) and postintubation (PostINT) stenoses in 111 cases/i.e. PostTS, n ¼ 72; PostINT, n ¼ 34; mixed: n ¼ 5, tumor-stenosis in 24 cases, tracheo-esophageal fistulas (T-Efist) in 17 cases, traumatic laesions in six and functional stenosis in five cases (Fig. 1). For these indications, the following procedures were performed: primary suture of traumatic tracheal wall was performed in five cases, laser intervention and tumor resections in three cases, segmental tracheal resection in 87 cases, and stenting in 68 cases. From among these 68 cases, 65 were solved by our own modification of Montgomery T-tube. That is why this Characterisation of our T-tube Our T-tube is actually a modified Montgomery T-tube [9] (Fig. 2). The main difference is that the horizontal branch of our tube is wider and is of an oval-shape. There are some advantages for this modification: (a) cleaning and toilette of such shaped T-tube is easier and more convenient as at the original one. (b) vertically oval-shaped tracheostomy (at the patients bearers of T-tube) allows easier extraction and reinsertion of the T-tube. (c) In general, the basic tendency is to keep the gap of the discission s tracheal stenosis segment open. The oval shape of horizontal branch is ideal to reach this goal. (d) Very significant and important fact in our conditions the prize of such a modified tube in comparison with all the other endoprosthesis is incomparably cheaper Indications and patients demographics In general, T-tube was applied in all cases of tracheal stenosis, where its radical segmental resection was not feasible. These applications were performed according to the standard indication criteria shown in Table 2. Our modified T-tube was applied to 65 patients (Table 1): 42 males and 23 females with a mean age of 49 years. The youngest among them was 10 years old and the eldest was- 79 (10 79 years). Indications for T-tube insertion were: PostTS in 27 cases, PostINT in 7 cases, mixed (PostTS þ PostINT) in 4 cases, tumors in 17 cases, T-Efist in 7 cases, functional stenoses in 3 cases Procedures The group of T-tube patients is not homogeneous. It contains patients with benign tracheal diseases ðn ¼ 46Þ; with malignancies ðn ¼ 19Þ/i.e. 17 patients with tracheal tumors and 2 patients with malignant T-Efist (Table 1). Table 1 Procedures and indications of trachea interventions (a complex table) Segm. Res. T-tube Other stents Suture Laser Sleeve pulm Exstirpation Total PostTS PostINT Mixed Tumors T-Efist Trauma Functio Total

3 A. Pereszlenyi et al. / European Journal of Cardio-thoracic Surgery 25 (2004) (c) a single intervention in 51 cases. Indications were: PostTS in 22 cases, PostINT in 7 cases, functional stenosis in 3 cases, malignancies in 19 cases (17 tumors and 2 malignant T-Efist). Generally, this group includes patients with long and multi-segment stenoses, and also patients with severe comorbidity, where the radical segmental resection was not feasible. (Table 3). 3. Results Fig. 2. Our own modification of Montgomery T-tube. In accordance with our standard indication criteria (Table 2) the T-tube was inserted as: (a) a temporary stent before segmental resection in 12 cases. From among these cases 4 patients had PostTS, 4 patients had PostINT þ PostTS and 4 patients had benign T-Efist. The first eight patients already underwent successful segmental tracheal resection with end to end anastomosis and their T-tubes were definitely removed. Four patients with benign T-Efist, where the T-tube was inserted not long ago, are awaiting for the definitive solution in the near future. (b) a temporary stent after segmental resection in 2 cases. These ones, with benign T-Efist, involved two young patients after car accidents. Their T-tubes were successfully removed after 10 and 15 months, respectively. Table 2 Standard indication criteria for T-tube application Before segmental resection as a temporary stent Complicated tracheal laesion Significant inflammatory changes on trachea Tracheo-esophageal fistula Non-compliant patient As the last group of patients in the previous chapter, where the T-tube was applied as a single intervention ðn ¼ 51Þ and which contains different diagnosis/indications/, is the largest one, the cases are being analyzed in more details (Table 3) Benign tracheal stenoses Posttracheostomy tracheal stenoses (n ¼ 22) From the total group of 22 patients/11 females and 11 males with mean age of 44.8 years (15 77 years), 50% of patients were already successfully extubated within 3 to 90 months. The second half of patients is still wearing the T-tube (time period from 2 to 118 months). These patients are constantly followed, their prognosis differs, some of them are candidates for extubation Postintubation tracheal stenoses (n ¼ 7) From the total group of 7 patients/2 females and 5 males with mean age of 57.7 years (42 72 years), 71% ðn ¼ 5Þ of Table 3 Indications for T-tube application Before segm. resection Complicated lesions PostINT þ PostTS PostTS Total 12 After segm. resection T-E fist After segmental resection Considering non-reliable suture (inflammation, tension) as a prevention of restenosis Anastomosis insufficiency, margins separation, restenosis Obstructions in the area of vocal cords Total 2 As a single procedure 2 As a single intervention Non-resectable tumors Long stenotic segments (over 50%) Multi-segmental stenoses Accompanying problems, which contra-indicate segmental resection (fibrosis, inflammation in the surrounding area, situation after repeated interventions) Nonresectable tu T-E fist (malign) Long and multisegm. stenoses Function PostTS PostINT Total 51

4 1062 A. Pereszlenyi et al. / European Journal of Cardio-thoracic Surgery 25 (2004) patients were freed from the T-tube within 2 to 18 months. One patients is still wearing the T-tube for 14th month, and one patient who wore the tube for 24 months died on heart failure Functional stenoses (n ¼ 3) We inserted the T-tube to a 21 year old patient with relapsed polychondritis with a long-term tracheostomy 18 months ago. Nowadays, he still wears the T-tube, undergoes regular check ups at our outdoor patients department. The other 69 year old male patient was admitted to our department from the otorhinolaryngologists with his diagnosis of osteoplastic tracheopathy. The patient immediately underwent longitudinal discission of tracheal front wall and granulation extraction. The T-tube then was inserted through tracheofissure tracheal opening. The patient is still wearing the T-tube and undergoes regular check ups at our outdoor patients department. The case of the third 63 year old female patient with functional tracheal stenosis will be described detailly below (in Section 3.3) as a case of tracheal rupture immediately after the Dumon stent application. It is important to underline that the group of patients with functional stenosis is not a homogeneous one, it includes several different diagnoses and we placed all of these cases together only from the schematic point of view Malignant tracheal stenoses Non-resectable tumors, malignancies (n ¼ 19) This group includes 2 patients with malignant T-Efist and 17 patients with non-resectable malignant tumors, which caused tracheal stenosis. The prognosis of these patients is dependent on the degree of advancement of their malignant disease. Due to its nature in most cases it is not favorable. The patients are being treated in local oncological departments in the region of their residence according to the progression of their disease. The 2 patients with malignant T-Efist were male, aged 59 and 68 years. The histology of their underlying diseases were squamos cell esophageal cancer and malignant lymphoma, respectively. They both died two and three months after the intervention. In the group of 17 patients there were 7 patients with malignant goiter and 10 patients with other (primary and secondary) malignancies. In all cases with malignant goiter the indication for urgent surgical intervention was primarily to ensure patency of the upper respiratory ways, secondarily to gain histologization of tumors. All these patients underwent tracheofissure, discission of tracheal front wall, insertion of T-tube. In all cases it was an advanced malignant tumor where the radical surgical resection was not feasible. Four patients had already had pulmonary metastases in the time of tracheal intervention. From the total of seven patients we lost 3 patients to follow-up, the mean survival of the rest four patients is 4.8 months. Demographically this group consisted of 3 females and 4 males with the mean age of 61 years. The remaining 10 cases involved: 3 cases with tracheal adenocarcinoma, 2 cases with tracheal squamos cell carcinoma, 2 cases with mediastinal malignant lymphoma, 2 cases with osephageal (laryngeal) spinocelular carcinoma and the last 1 case with metastasis of Grawitz tumor. Demographically these 10 cases are: 3 females, 7 males with a mean age of 59.4 years (45 69 years). The mean survival for the above patients were 3.5 months. Finally, we can only state that the results in treatment of such patients with malignancies, where the radical surgical intervention cannot be performed, are burdened with high mortality rate. However, we believe, that to ensure respiratory ways by a T-tube and thus to make patient s quality of life better, is very important. We also must not forget the fact that recently the number of such patients is increasing Follow-up of T-tube bearers, observation of tracheal mucous membrane reaction to T-tube It follows from the above-mentioned, that from among 51 patients who received T-tubes within single procedure, 15 patients are still under our regular follow-up. Their diagnosis are: 3 patients with functional tracheal stenosis, one with postintubation and 11 patients with posttracheostomic tracheal stenosis. The follow up period of T-tube wearing ranged from 2 to 118 months (mean 46.1 months). Our regular record of check ups were reduced by 19 patients with malignancies (death), and by further 17 patients (PostTS and PostINT), who were already successfully extubated and released. During the regular check-ups of T-tubes patients, besides other activities we also removed biopsies from the tracheal mucous membrane and studied the reaction of mucosa on endoprosthesis. During the stenting procedure by any type of endoprosthesis there was no evidence of creation of a full-valued, original respiration epithelium. Only metaplastic changes of mucous layer could always be seen, no matter which type of endoprosthesis was used. This metaplasis was created by squamous cells with their hyperplasy, however, without dysplasia. On the surface layers parakeratosis was found; the top layers were usually covered by a film that contained polymorphonuclears. Lamina propria layers are always infiltrated by chronic inflammatory infiltrate. We can always observe these changes, but they were found most considerable after trachea stenting by metallic endoprosthesis. In all kinds of trachea reconstruction a relatively good toleration of silicone material was observed. Silicone T-tube causes minimal complications. Obstruction of T-tube by dense sputum, which required the T-tube removal and is

5 A. Pereszlenyi et al. / European Journal of Cardio-thoracic Surgery 25 (2004) replaced by a double-coated tracheostomy tube, was the most common complication. The location, where most complications occurred was the upper part of the T-tube, in the place from where it was inserted to subglottic area. Here, irritations and granulations could be sporadically observed. It is really difficult to estimate the correct length of the upper end of the T-tube s vertical branch. For this reason it was necessary to perform endoscopic checks with the adjustment of the tube s upper end (due to the close position of vocal cords, and due to a necessity of granulations overbridging). After insertion of the T-tube s upper vertical part through vocal cords and its long-term positioning in this area, significant changes of vocal cords were not observed. After the removal of the tube, the patient s voice spontaneously appeared, even though it was not always clear Results of other endoprosthesis stenting In order to complete this chapter, results after stenting by other traditional endostents will be briefly described. This stenting was performed in 3 patients: i.e. the dynamic tracheobronchial stent was inserted in 2 cases, and the Dumon stent was inserted to one patient (Table 1). The tracheobronchial stent was applied to the 60 year old male patient with malignant T-Efist (squamous cell esophageal carcinoma). The patient tolerated the stent very well, the respiratory ways were ensured this way very well, too. This patient, however, died 6 months later due to progression, generalization of his malignant disease. In another case this stent was inserted to a 40 year old male patient with a compressive, extramural tracheal stenosis caused by mediastinal tumor (originally histological leiomyoma). For its aggressive pressing attributes we were forced to perform a right-sided pneumonectomy and change the original stent for another one with its shorter right and upper-vertical branch. The patient died a month later due to the expansive character of the tumor (pressing of great vessels and cardiac arrest), the histology of tumor was re-classified as a leiomyosarcoma. The Y-shaped Dumon stent was applied to a 63 year old female patient with functional tracheal stenosis. As this insertion was complicated by tracheal rupture, an urgent right-sided thoracotomy with stent extraction and coverage of the rupture by pleuromusculoperiostal flap, followed by T-tube stenting were performed (Table 1). 4. Discussion Nowadays, the topic of tracheal reconstruction is becoming more and more up-to-date, mainly due to growing problems with postintubation stenoses [1 3]. The number of complicated tracheal laesion increases, mainly those cases where the resection (and anastomosis) is unsuccessful or is not feasible, the situation often requires solution only by endoprosthesis [4 6]. Among numerous types of endoprosthesis the best ones, which were proven by time, are made of silicone [10,11].In our study our own modification of Montgomery silicone T-tube was used [9]. Its greatest advantage is that this T-tube serves as an internal stent as well as a tracheostomic tube. Its smooth and non-immerse surface restricts the mucous sputum adherence and incrustation creation. It has to be said that the silicone gum material is so far the best material for temporary tracheal stenting. It is rigid enough to restrict the narrowing of tracheal lumen during the granulation tissue maturation, and in the other hand it is fine (smooth) enough to allow the tracheal epithelium growth through granulations [9,12]. The therapy of stenting is time-consuming. The period of time necessary for trachea wall stabilization and trachea mucosa healing differs from case to case, that is why the time of wearing the T-tube by our patients was different. In our study the mean time to wear the T-tube is 26.4 months (including patients with permanent T-tube). In the end phase of tracheal reconstruction we perform our own original technique of tracheoplasty using perforated autologous rib cartilage [2]. Silicone T-tube was applied to 65 patients; to patients with benign tracheal stenoses in 46 cases, to patients with malignant disease in 19 cases. The mean age of those patient was 49 years. The success of treatment by T-tube is given by safeness of this modality. Silicone T-tube is more safe than any other endoprosthesis, because it creates a smooth regenerated surface and there is a great probability of extubation or possible resection, respectively. As it was already described above, our T-tube mainly differs from the Montgomery one by its horizontal branch, which is wider and vertically ovalshaped (Fig. 2). There are several advantages of this modification, they are detaily described in the paragraph above (T-tube). In our study management of posttracheostomic and postresection tracheal stenosis, and also tracheo-esophageal fistula stenosis by T-tube, where the previous efforts for reconstruction failed, was the most successful. We mainly appreciated the advantages of stenting by T-tube in those cases, where the segmental resection is not feasible or its too risky. In special situations T-tube is the most effective solution: it enables verbal communication to the patient, allows natural ventilation (per vias naturales) and overbridges the periods necessary for a definite tracheal stenosis solution. Besides incomparably better comfort for the patient, it ensures an effective stenting of respiratory ways. Additionally this study allows to compare the group of 87 patients after radical segmental resection with a group of 65 patients after T-tube stenting. It is evident from the data that the success of segmental resections is higher than it is after conservative treatment. Segmental tracheal resection ðn ¼ 87Þ was successful in almost all cases (96%). Eightyfour patients left the hospital in good condition, their tracheal stenoses were definitely solved by all the mentioned procedures. In three patients re-resection in early

6 1064 A. Pereszlenyi et al. / European Journal of Cardio-thoracic Surgery 25 (2004) postoperative period was necessary. After that their further postoperative course was uneventful. Only 41.6% of patients after conservative treatment ðn ¼ 65Þ can be classified as success, i.e. the T-tubes were successfully removed in 27 cases. (In 19 patients (29.2%) the stenting is still continuing, but they are candidates for tube extraction in the near future. In 19 patients (29.2%) with malignancies the T-tube was applied only as a palliation. All of these patients died.) It must be emphasized that in the group of patients managed by the T-tube the success rate is evidently smaller, but despite this treatment modality it often remains the only possible solution for patients in apparently deadlock situations. As it was emphasized in the Introduction (Section 1) already, tracheal stenosis is a serious disease with increasing tendency. Among this increased number of tracheal stenosis complicated, multi-segmental, long stenoses can be found. Also there is an increasing number of patients with nonresectable tumors and patients after segmental tracheal resection with a developed anastomotic insufficiency. In such cases, dramatic situations, the only optimal solution is to use a conservative way with T-tube stenting. References [1] Grillo HC, Donahue DM, Mathisen DJ, Wain JC, Wright CD. Postintubation tracheal stenosis. Treatment and results. J Thorac Cardiovasc Surg 1995;109(3): Discussion [2] Harustiak S, Majer I, Benej R, Pereszlenyi Jr A, Bohucky S, Jurakova O, Dzuberova I, Kajanovicova V. Tracheal stenosis and its treatment. Bratisl Lek Listy 1999;100(6): [3] Grillo HC. Surgical treatment of postintubation tracheal injuries. J Thorac Cardiovasc Surg 1979;78(6): [4] Massard G, Rouge C, Dabbagh A, Kessler R, Hentz JG, Roeslin N, Wihlm JM, Morand G. Tracheobronchial lacerations after intubation and tracheostomy. Ann Thorac Surg 1996;61(5): [5] Jougon J, Ballester M, Choukroun E, Dubrez J, Reboul G, Velly JF. Conservative treatment for postintubation tracheobronchial rupture. Ann Thorac Surg 2000;69(1): [6] Jacobs JP, Quintessenza JA, Botero LM, van Gelder HM, Giroud JM, Elliott MJ, Herberhold C. The role of airway stents in the management of paediatric tracheal, carinal and bronchial disease. Eur J Cardiothoracic Surg 2000;18: [7] Cooper JD, Todd TR, Ilves R, Pearson FG. Use of the silicone tracheal T-tube for the management of complex trachea injuries. J Thorac Cardiovasc Surg 1981;8(4): [8] Liu HC, Lee KS, Huang CJ, Cheng CR, Hsu WH, Huang MH. Silicone T-tube for complex laryngotracheal problems. Eur J Cardiothorac Surg 2002;21(5): [9] Montgomery WW. T-tube tracheal stent. Arch Otolaryngol 1965;82: [10] Neville WE, Bolanowski PJ, Kotia GG. Clinical experience with the silicone tracheal prosthesis. J Thorac Cardiovasc Surg 1990;99: [11] Cooper JD, Pearson FG, Patterson GA, Todd TR, Ginsberg RJ, Goldberg M, Watters P. Use of silicone stents in the management of airway problems. Ann Thorac Surg 1989;47(3): [12] Pearson FG. Technique of management of subglottic stenosis. Chest Surg Clin N Am 1996;6(4): Appendix A. Conference discussion Dr. R. Santosham (India): You didn t mention the complications. Did you have any tracheoinnominate artery fistulas, especially during the learning curve? Any other problems - restenosis, residual stenosis, recurrent laryngeal nerves paralysis? These are the things that are important in any series of tracheal surgery. Dr. Pereszlenyi: As I was given only 5 minutes for this presentation, I mainly wanted to focus on the stenting by our own modification of the Montgomery T-tube. In the written paper you can find a whole chapter on complications also during the learning curves as well as on the T-tube patients follow-up period. As it is known, stenting procedure with the T-tube is time consuming, also due to the fact that each patient had to be treated individually, accurately with periodical checks in the follow-up period. Dr. W. Weder (Zurich, Switzerland): You observed 111 postintubation tracheal stenoses. This is an enormous number. Don t you use low-pressure tubes in your country? Dr. Pereszlenyi: In my country the indications, the vast majority of the mentioned 111 cases, underwent procedures at the very beginning of 1990s, and that time we had no low-cuff tracheostomy tubes. And I have to clarify again that these 111 patients were of both: posttracheostomic and postintubation stenoses, i.e. 111 were not only postintubation stenoses. There was also a large group of posttracheostomic ones. Dr. Weder: But in 10 years, also after tracheostomy, what kind of technique of tracheostomy do you use that you have such a high number of stenoses thereafter? Dr. Pereszlenyi: All these patients (total - 163) were referred to our institution, our clinic from all around Czechoslovakia, and after the division - Slovakia. So, it means that the vast majority of the cases were not from our hospital (we were only solving the complications originated elsewhere). I participated in the Slovak National Anesthesiology Congress and discussed the topic on the problems related with performing of tracheostomy. Dr. T. Orlowski (Warsaw, Poland): It should be stressed also that sometimes this is the result of the laser usage which enlarges the segment of the stenosis. Dr. G. Friedel (Gerlingen, Germany): You have a large group of patients who were treated preoperatively by T-tube. I don t really understand these cases. Why do you treat them preoperatively? Dr. Pereszlenyi: The group of patients, where the indication for T-tube application was preoperatively performed, involves a lot of different diagnoses, a lot of different indications. Also, there are patients in bad condition, intubated, who are not able to cooperate. But the condition of some of them after the successful intensive care management improved to such level that the segmental tracheal resection became feasible.