Tracheal Obstruction. G. Robert Mason, M.D., Ralph Ramirez, M.D., and. Safuh Attar, M.D., John Hankins, M.D., Stephen Turney, M.D.

Transcription

1 Tracheal Obstruction Safuh Attar, M.D., John Hankins, M.D., Stephen Turney, M.D., G. Robert Mason, M.D., Ralph Ramirez, M.D., and Joseph McLaughlin, M.D. ABSTRACT Tracheal obstruction, a life-threatening emergency that requires immediate therapy, manifests itself by cough, wheezing, exertional dyspnea, hemoptysis, and respiratory arrest. Thirty-three patients with tracheal obstruction were studied 17 had tracheal stenosis secondary to tracheostomy and ventilatory assistance, 7 had primary tracheal tumors, and 9 had either secondary tracheal tumors or extrinsic compression by esophageal or thyroid tumors. The diagnosis of tracheal obstruction was confirmed by roentgenograms of the trachea and bronchoscopy. The ideal treatment for tracheal obstruction caused by benign tracheal stenosis or malignant tumors is primary resection with end-to-end anastomosis. Cobalt therapy with or without surgical resection provides good palliation for extensive primary or secondary tracheal tumors. T racheal obstruction is a life-threatening emergency that requires immediate therapy. It can develop insidiously but manifests itself suddenly. The causes of tracheal obstruction are either congenital or acqui red, the most common cause of tracheal obstruction on a congenital basis being vascular ring. Congenital tracheal stenosis of the localized or diffuse type is rare; 24 cases have been reported in the literature [14]. The majority of the reported patients died in infancy, though a few have survived on conservative treatment. The acquired type of tracheal obstruction is caused by (1) foreign bodies, (2) tracheal intubation, or (3) tumors, either intrinsic-arising primarily from the trachea-or extrinsic-arising from the surrounding organs such as thyroid, esophagus, and so forth. This paper reviews our recent experience with tracheal obstruction, excluding that caused by vascular rings and foreign bodies. It reflects a significant increase in the incidence of tracheal obstruction secondary to posttracheostomy intubation. The occurrence of primary tracheal tumors remains relatively rare and has not paralleled the increasing incidence of primary cancer of the bronchi and larynx. The diagnosis is usually delayed because of the paucity of identifying symptoms and findings. Recent advances in early diagnosis and treatment are discussed. From the Department of Swgery, Division of Thoracic and Cardiovascular Surgery, University of Maryland School of Medicine and Hospital, Baltimore, Md. Supported by U.S. Public Health Service Grant HE Appreciation is expressed to the surgeons who participated in the management of these patients and permitted us to include them in the paper: Drs. Cyrus Blanchard, Michele Cerino, Frank A. Faraino, Miguel Gonzales, Jose Iglesias, and John E. Miller. Presented at the Nineteenth Annual Meeting of the Southern Thoracic Surgical Association, Port of Spain, Trinidad, Nov. 2-4, Address reprint requests to Dr. Atta.r, University of Maryland Hospital, 22 S. Greene St., Baltimore, Md VOL. 16, NO. 6, DECEMBER,

2 ATTAR ET AL. Clinical Material The medical records and roentgenograms of 33 patients presenting with tracheal obstruction were reviewed. Twenty-seven patients were treated at the University of Maryland Hospital and 6 were treated in community hospitals. The patients were classified into three groups according to the underlying etiology of tracheal obstruction: Group A consisted of patients with tracheal stenosis, Group B included patients with primary tracheal tumors, and Group C comprised patients with tracheal obstruction secondary to extrinsic tracheal compression. GROUP A: TRACHEAL STENOSIS Group A consisted of 17 patients with tracheal stenosis (Table). There were 13 men and 4 women ranging in age from 18 to 70 years. The etiology of the stenosis was prolonged endotracheal intubation for ventilatory assistance. The policy in our intensive care unit for patients requiring ventilatory support is to intubate them with an endotracheal tube for 24 to 48 hours. If further respiratory assistance is anticipated, a tracheostomy is performed. Silver-Jackson tracheostomy tubes with latex s are used for the first few days, followed by modified Portex tubes. Sterile gloves and catheters are used for tracheal aspiration, and the s are deflated for 5 minutes every 2 hours. The indications for tracheostomy and ventilatory support were chest injury with flail chest in 5 patients, head injury in 5, necrotizing pneumonia in 2, chronic respiratory insufficiency in 2, postoperative care following open-heart procedures in 2, and cardiac arrest following aneurysmectomy in 1. Tracheal stenosis occurred at the tracheostomy stoma in 3 patients and at the level of the between 1.5 and 3.5 cm. below the tracheostomy in 11. Two patients developed stenosis at both the stoma and the distal trachea (see Table). Patients B. B. and I,. S. required three tracheostomies because of chronic respiratory insufficiency in one and brain damage following multiple trauma in the other. Another patient (A. F.) had stenosis at the site initially. This was resected, and a second tracheostomy was performed one month later because of Pseudomonas pneumonia. A second stenosis occurred at the site of the previous resection six months following the second tracheostomy. The period of intubation varied from 7 to 90 days with an average of 28 days. An asymptomatic interval was observed from the time of extubation to the onset of tracheal obstruction. This period varied from 1 to 24 weeks with a mean of 9 weeks. In general, the longer the period of intubation, the shorter was the asymptomatic interval, though exceptions were noted (see Table). The symptomatology of tracheal stenosis was uniform. Nearly all patients developed increasing shortness of breath after the asymptomatic period. 556 THE ANNALS OF THORACIC SURGERY

3 Tracheal 0 bstruction FIG. I. Lateral view of the trachea. Note the segment of tracheal stenosis with significant narrowing of the air column above the tracheostomy tube. This gradually progressed between 1 and 4 weeks to increasing respiratory distress with inability to raise secretions, stridor, and temperature as high as 104 F. The respiratory distress was so severe in some patients that they became markedly cyanotic and apprehensive despite oxygen therapy and steroids. These were operated upon as emergencies. The diagnosis of tracheal stenosis was made in all patients except for H. S. This patient had undergone aortic and mitral valve replacement and developed increasing shortness of breath with evidence of heart failure three months following tracheostomy. Another tracheostomy was performed, but attempts at intubation were unsuccessful because of marked tracheal stenosis. The diagnosis of tracheal stenosis was confirmed by roentgenograms and bronchoscopy. Lateral films of the neck demonstrated some lesions involving the upper part of the trachea (Fig. 1). Chest roentgenograms were helpful in ruling out other causes of tracheal obstruction and demonstrating any pneumonic process. Tracheal films (Fig. 2) were taken after temporary removal of the tracheostomy tube since the latter usually obscures the area of stenosis. Accurate localization of the stenotic area and determination of its extent and relationship to the tracheostomy stoma were essential information prior to any surgical intervention. Fluoroscopy of the trachea, preferably recorded on cine films, identified any areas of malacia proximal to the stenosis. Tracheograms (Fig. 3) with contrast medium provide an excellent outline of the stenosis, but to avoid further respiratory embarrassment they were not utilized routinely. Bronchoscopy was done in all patients for diagnostic and therapeutic purposes. It helped define the nature of the stenosis, whether it VOL. 16, NO. 6, DECEMBER,

4 cn CTI 00 Patient, Age, ac Sex H. S., 48, M G. C., 34, F B. B., 67, M TRACHEAL STENOSIS IN 17 PATIENTS DUE TO PROLONGED ENDOTRACHEAL INTUBATION (GROUP A) Period After Tracheostomy Duration of Indications for Intubation Where Mechanical Method of Operative (days) Performed Ventilatinn Treatment Approach Site of Stenosis Result 3 mo. 8 3 mo. 7 Left atrial ; distal trach. M. B., 48, M 1.5 mo. 24 G.L., 21, M W.H., 31, M A.H., 31, M R. W., 38, F 2.5 mo. 1 wk. 3 mo. 1.5 mo UMH Double-valve Tracheostomy None replacement, CHF UMH Mitral valve Dilation None replacement Outside Chronic resp. Endotrach. None hospital insuff.; re- intubation peated cardiac arrests UMH Down s syndrome; Segmental resec- Cervical bilateral aspira- tion, 1 y2 cm. tion; bronchopneumonia Outside Cerebral Segmental resec- Cervical tion, 1% cm. mediastinal Head injury Segmental resec- Cervicohospital concussion tion, 2y2 cm. Flail chest; shock; Segmental resec- Cervical lung & renal tion failure Outside hospital Outside hospital U tured spleen both femurs, pelvis; ruptured Blunt chest in- jury; fractures: mandible, ribs, MH Segmental resec- Cervicojury; tion, 2v2 cm. mediastinal R. S. S., 66, M Cuff 1.5 mo. 10 Outside Chronic lung Segmental resec- Cervical left diaphragm noma; paralyzed dis.; broncho- genic carcinoma; hospital tion, 3 cm. Cardioresp. arrest thrombus; died Tracheomalacia with necrosis of trachea; died Excellent Excellent Excellent Excellent Removal of granulation tissue at site of anastomosis lv2 mo. postop.; good Disruption of anastomosis 7 days postop.; perm anent tracheostomv:

5 V.L., 59, M A. F., 70, F F. L., 63, M M. K., 56, M w Q, L. S., 18, F P z Q, L A.N., 47, M CD -3 w J. M., 19, M stoma Stoma Cuff 2-3 ~m. below trach. Stoma above carina 3 mo. 4.5 mo. 2 mo. 7 wk. 6 wk. 3 wk. 6 mo UMH UMH UMH UMH Outside hospital UMH UMH fractures membrane l(c insertion of tracheal stent; tracheostomy Resected abdom. Tracheostomy & Cervical Died while aneurysm; MI dilation of awaiting resecwith cardiac stricture tion of stricture arrest Car accident: Tracheostomy Cervico- Fair; tracheostomy flail chest (2nd); segmen- mediastinal; for 5 mo. foltal resection, left thora- lowing resection; 3 cm. cotomy restenosis; stent; excellent Pulm. contusion; Segmental resec- Cervical Good fractures, ribs tion, 21/2 cm ; flail chest; chronic obstructive airway dis. Diabetic keto- Tracheal dilation; Cervical & sternal Excellent acidosis; necroti- segmental re- splitting zing pneumonia section, 4 cm. tion, 2% cm. mental resectiple Dilations & resection of granulation tissue & false tracheostomy tract ; tr acheos- tomy; segmental resection, 5 cm. Tracheostomy & dilation; seg- Cervico- Survived 5 mo. mediastinal; following right thora- tracheal resectures cotomy tion, died of renal failure & brain injury Cervical & sternal Excellent splitting Brain edema; Tracheostomy; Cervico- Excellent pulm. con- segmental re- mediastinal tusion section, 41/2 cm. UMH = University of Maryland Hospital; CHF = congestive heart failure; MI = myocardial infarction.

6 ATTAR ET AL. FIG. 2. Preoperatizre roentgenogram showing narrowing of the thoracic trachea. Note the long segment of tracheal stenosis. was soft or cicatricial, and its extent; and in some cases it was done repeatedly to excise redundant granulations. Cultures of the tracheal secretions were obtained and appropriate antibiotics given preoperatively. The predominant bacteria were Pseudomonas, Staphylococcus, and Escherichia coli. Light general anesthesia was induced following tracheal intubation under topical anesthesia. The anesthetic gases were delivered through the FIG. 3. Tracheogram (L. S.; see Table) showing narrowing of the distal trachea above the carina. Left: oblique view; right: anteroposterior view. 560 THE ANNALS OF THORACIC SURGERY

7 Tracheal 0 bstruction tube placed above the lesion. For high lesions a cervical approach was adequate. For lesions below the thoracic inlet a cervicomediastinal approach was utilized. For lesions of the lower trachea a right thoracotomy was performed. In only 1 patient (A. F.) a left anterior thoracotomy was done, concomitantly with the cervicomediastinal incision, to explore a persistent air leak. The area of stenosis was usually identified without difficulty and ranged from 1.5 to 5 cm. in length. Dense scarring and fibrosis surrounded the area of stenosis. Particular attention was given to the esophagus, which was identified by an indwelling nasogastric tube. No attempt was made to identify the recurrent laryngeal nerves, which were avoided by keeping the dissection close to the trachea. When a tracheostomy stoma was present, it was incorporated and excised with the cervical incision in the case of a high stenosis. When the area of stenosis was low in the mediastinum, the tracheostomy stoma was excluded from the operative field and healed without difficulty. Following exposure of the trachea, two heavy-traction Tevdek sutures were placed in the normal trachea above and below the stenotic area to release tension on the suture line. Dissection was limited initially to the anterior wall of the trachea. Mobilization of the lateral wall of the trachea was avoided to preserve the segmental blood supply. The trachea was then divided in the area of the stricture, and anesthesia was maintained through a ed Tovel tube inserted through the distal segment of the trachea. The stenotic area was then excised and the posterior wall of the trachea freed down to the carina by blunt finger dissection. Interrupted 4-0 Tevdek sutures were used for the anastomosis. The posterior row of sutures was inserted first, followed by the anterior suture line. It is important to tie the posterior sutures first while the traction sutures are pulled together to release tension on the suture line. The Tovel tube was then removed and the anterior suture line completed. The anastomosis was checked for air leaks. Following wound closure, the chin was sutured to the anterior chest wall with two heavy Tevdek sutures to minimize tension on the tracheal suture line. These sutures were usually removed in 10 days. Twelve patients underwent tracheal resection: 7 had a cervical and 5 a cervicomediastinal approach through sternal splitting. One patient (L. S.) underwent operation using a cervicomediastinal approach for a high stenosis. A long tracheostomy tract was found obstructing the upper trachea, and the tract was excised. Her condition was complicated by an empyema of the right pleural cavity. Five months later a low tracheal stenosis was demonstrated above the carina (see Fig. 3) and was excised through a right thoracotomy. Tracheostomy with dilation of the area of stricture was the initial treat. ment in 4 patients: 3 had resection subsequently, and 1 (H. S.) died at the time of tracheostomy because of inability to bypass the stricture. An additional patient (R. S.) was treated in another hospital by tracheostomy below VOL. 16, NO. 6, DECEMBER,

8 ATTAR ET AL. the area of the high stenosis, incision of the stenotic area, and insertion of a stent that was removed a month later. Results of the surgical treatment of tracheal stenosis have been satisfactory. Of the 12 patients who underwent resection, 8 had excellent results with restoration of a normal airway. Two patients had good results but required removal of granulation tissues one and a half and twelve months postoperatively, respectively. A third patient (A. F.) had a Pseudomonas infection of the tracheostomy incision and airway prior to tracheal resection. Repeated bronchoscopies were done postoperatively to remove granulation tissues. Pseudomonas pneumonia developed three months later, necessitating a third tracheostomy. The tracheostomy was removed after five months, but the patient developed tracheal obstruction in the subglottic area at the site of anastomosis 20 days following extubation. Repeated tracheal dilations failed to relieve the obstruction. A second operation was required, dividing the subglottic stricture and using a split-thickness, skin-covered Portex tube as a stent through which the tracheostomy tube was inserted distally into the trachea. The stent was removed 6 weeks later, resulting in an excellent open airway. GROUP B: TRACHEAL TUMORS There were 7 patients, 4 men and 3 women, ranging in age from 21 to 65 years, who had primary tracheal tumors. The average duration of symptoms from their onset to diagnosis was one year, ranging from several weeks to two years. Cough, dyspnea, and asthmatic wheezing were the most frequent and earliest complaints. Hemoptysis was a common but late symptom that brought the patients to the hospital. The patients were treated for asthma, emphysema, pneumonia, and pulmonary infarction for months or years prior to the diagnosis of tracheal tumor. Two patients coughed up pieces of tissue that gave the clue to the diagnosis. The diagnosis was suspected from roentgenograms of the trachea and confirmed by bronchoscopy and tissue biopsy. In 4 patients the tumor was located in the distal third of the trachea, in 2 in the middle third, and in 1 patient the tumor extended from the second tracheal ring to the bifurcation of the carina and involved the proximal part of both bronchi. Pathologically, there were four squamous cell carcinomas, one small spindle cell carcinoma, and two cylindromas. Four patients with carcinoma were treated with 6,000 rads of cobalt 60. Only 1 patient (E. M.) received 6oCo and chemotherapy. Six months later she became obstructed, however, and bronchoscopic excision of pedunculated tumor tissue was necessary for palliation. Resection of the distal third of the trachea with primary anastomosis was performed one year four months from the onset of symptoms. She remained asymptomatic for six months, at which time she developed shortness of breath and hemoptysis. Partial excision of the tumor was performed through the bronchoscope. Symptoms of tracheal 562 THE ANNALS OF THORACIC SURGERY

9 Tracheal Obstruction obstruction recurred four months later, and exploratory thoracotomy revealed invasion of the superior vena cava. G. S., 1 of the 2 patients with cylindroma, had resection of all the thoracic trachea as a palliative measure since he had nearly complete obstruction. A prosthesis of tantalum mesh surrounded by fascia lata was sutured airtight into place to replace the excised tracheal segment. The second patient (M. S.) underwent resection of a sessile growth over the right posterolateral portion of the lower third of the trachea with primary anastomosis. The patient remained asymptomatic for two and one-half years, at which time she developed stridor. Recurrence of the tumor was confirmed by bronchoscopy. The tumor was excised, removing 6 cartilaginous rings with the specimen. Approximately half of the circumference of the trachea was excised, and the tracheal defect was closed using an intercostal pedicle flap. Four years later the patient was alive but had recurrence at a higher level in the trachea. Of the 4 patients with carcinoma of the trachea who were treated with 6oCo, 2 are alive and well without evidence of recurrence of tumor six months and three years, respectively, following cobalt therapy. The other 2 patients died, 1 three months later without relief, whereas the other had a good immediate response, but the tumor had extended to the surrounding tissues before cobalt therapy was instituted. Only 1 patient (E. M.) underwent resection of the trachea following cobalt therapy for squamous cell carcinoma. She died less than two years after resection with invasion of the superior vena cava. The 2 patients with cylindroma were treated surgically. G. S., who underulent resection of the whole thoracic trachea, exsanguinated 20 days postoper;ltively when a microabscess developing between the prosthesis and the surrounding soft tissues ruptured into the aorta. The other patient (M. S.), who had two surgical excisions of the tumor, is alive with recurrence of the tumor eight years later. GROUP C: TRACHEAL OBSTRUCTION BY EXTRINSIC COMPRESSION OR SECONDARY TUMORS The 9 patients with tracheal obstruction in this group ranged in age from a newborn baby to 72 years and included 4 males and 5 females. Two patients had carcinoma of the lower third of the esophagus, 2 had bronchogenic carcinoma with extension of the tumor into the carina and lower trachea, 1 had lymphoma invading the trachea, 1 had follicular adenocarcinoma of the thyroid invading the trachea and esophagus, 2 had a large aortic aneurysm in the ascending aorta, and the newborn baby had teratoma of the thyroid. They all presented with symptoms of respiratory distress necessitating immediate therapy. One patient, who was 17 years old, first noticed a tightness around his neck. Two weeks later he had a sudden respiratory arrest. He was resuscitated by mouth-to-mouth breathing and intubated. Chest VOL. 16, NO. 6, DECEMBER,

10 ATTAR ET AL. roentgenograms showed a mediastinal tumor that had compressed the trachea. An emergency operation using a cervicomediastinal approach was necessary to excise the tumor. When the tracheal obstruction was caused by a benign condition, resection of the underlying lesion, whether an aortic aneurysm or a benign tumor, was curative. Only 1 patient in this series, who had a recurrent follicular adenocarcinoma of the thyroid involving the trachea and esophagus, was treated by radical excision. Total laryngectomy with resection of the cervical esophagus and interposition of the colon was performed. The patient died two months later from erosion of the innominate artery. C o m m e n t Probably no other emergency in the field of medicine creates such a dramatic situation as that of acute respiratory obstruction. Immediate, effective action is required if a fatality is to be avoided. With the widespread use of tracheostomy for respiratory assistance, a sharp increase in acute respiratory obstruction due to tracheal stenosis has been observed. Andrews and Pearson [2] reported a 20 % incidence of obstruction in patients managed by tracheostomy and assisted ventilation. Extensive laboratory and clinical investigations have been reported in the literature in an effort to determine the etiology of such stenosis. Three major factors are probably responsible for the development of tracheal stenosis: excessive pressure, infection, and excessive movement of the tracheostomy tube [15]. Pressure necrosis by the inflated has been clearly incriminated as the primary etiological event in the development of circumferential stenoses which follow the use of ed tubes [5]. The pathogenesis of stomal stenosis differs in several respects from that of cufl stenosis. A defect is created in the cartilage of the anterior tracheal wall that is susceptible to further destruction by both pressure and local infection. According to Andrews and Pearson [2], the inflatable lies only a few centimeters distal to the stoma, producing a circumferential compression of mucosal and submucosal blood vessels at this level. This may reduce the circulation and impair the vitality of that segment of tracheal wall between the stoma and the. A permanent defect in the anterior tracheal cartilage occurs, and, following extubation, the cartilage at the lateral margins of the stoma falls in-or is pulled in toward the midline-and the margins unite by fibrous scar. In evaluating the significance of individual factors in relation to tracheal stenosis, Andrews and Pearson [2] found the following: (1) tracheostomy tubes of larger diameter were associated with an increased incidence of stricture at both the stomal and the level; (2) high-dosage steroids during the period of assisted ventilation were associated with a higher incidence of stomal stricture. In the case of hypotension and airway 564 THE ANNALS OF THORACIC SURGERY

11 Tracheal 0 bstruction infection, the association with an increased incidence of stenosis was suggestive. The contributions of Grillo [8-111 to an understanding of the pathology and evolution of tracheal stenosis and his determination of the limits of tracheal resection with primary anastomosis have established the present trends in tracheal surgery. Mulliken and Grillo [16] established that large segments of trachea may be excised circumferentially and continuity restored by primary anastomosis. An average length of 4.5 cm. of trachea may be resected and primary anastomosis accomplished extrapleurally by careful mobilization of the trachea through a cervical or cervicomediastinal approach and comfortable flexion of the patient s head between 15 and 35 degrees. An additional average length of 1.4 cm. may be obtained by intrathoracic and intrapericardial mobilization of the right hilum, making a total of 5.9 cm. (9.7 rings). In 1970, Grillo [lo] reported 30 patients with postventilatory stenosis who had undergone resection and primary anastomosis. There was only 1 death. Of the remaining 29 patients, 24 had good to excellent results. Fishman and his co-workers [7] reported 12 cases of postintubation tracheal stenosis. Six patients were treated by repeated tracheal dilations. No patient responded with permanent benefit unless it was possible to space the treatments at progressively greater intervals, up to a maximum of six dilations. Falbe-Hansen [6] reported 6 patients wtih poliomyelitis who developed tracheal stenosis following tracheostomy. The treatment was surgical removal of scar tissue, insertion of a polyethylene tube of suitable width and length in the stenosed area, and fixation of the tube to the skin. At the end of three to five months the tube was removed by direct laryngoscopy. The stenosis was cured in 5 out of the 6 patients. From our experience, it is suggested that resection of the stenotic area with primary anastomosis is the ideal treatment for posttracheostomy stenosis. Conservative management using repeated dilations is indicated in patients with chronic obstructive airway disease or some other medical contraindication to operation. It is hoped that with the use of good respiratory care and the large-volume, low-pressure, the incidence of tracheal stenosis can be reduced significantly. As far as tracheal tumors are concerned, it is fortunate that their incidence has remained low. In the experience reported by Houston and his associates [13], 1 tracheal cancer was diagnosed for every 180 lung cancers or 75 laryngeal cancers. The delay in diagnosing these tumors accounts for the poor results achieved in advanced cases. The nonspecific symptoms and absence of roentgenographic signs seem to be the major factors contributing to the delay. Bronchoscopy remains the most reliable means of establishing the diagnosis. Tracheal tumors occur most frequently in the lower third of VOL. 16, NO. 6, DECEMBER,

12 ATTAR ET AL. the trachea. The next site in frequency is the cervical or upper third of the trachea. The middle third is least often involved [13]. While epidermoid carcinoma is the most frequent cancer of the trachea, adenoid cystic carcinoma and mucus-secreting adenocarcinoma are also important lesions in this location. Adenoid cystic carcinoma (cylindroma) usually has a slow and insidious course, almost always recurs, produces metastasis, and ultimately kills by extensive local involvement of the vital organs [12]. At present, the treatment for tracheal tumors is either operation or radiotherapy or a combination of both. As demonstrated by Clark, Clagett, and MacDonald [4], the value of endoscopic resection and coagulation has proved to be mainly palliative. Sleeve resection and primary end-to-end anastomosis are superior to techniques employing partial circumferential patches or tubular prostheses. With the demonstration by Grillo [ 101 that an average 6.4 cm. of mediastinal trachea can be safely resected by full mobilization of the right lung and transplantation of the left main bronchus into the left intermediate bronchus, the indications for a prosthesis have practically been eliminated [ 181. Additional length could also be obtained by transecting the cervical trachea and advancing it into the mediastinum following appropriate dissection. Radiotherapy using 6OCo has not been given a full trial because of the rarity of these lesions. In our series, 5 patients were given 6,000 rads of 6oCo; 2 are alive without tumor recurrence at six months and three years, respectively. Two other patients received radiotherapy for palliation only. The fifth patient (E. M.) had 6OCo and tracheal resection but died of recurrence in less than two years. The use of a tubular prosthesis was stimulated by Beall [3] and Neville [ 171 and their colleagues. Beall reported 2 successful cases of circumferential replacement of intrathoracic trachea with Marlex mesh. Yeh and his colleagues [ 191 reported partial excision of the thoracic trachea with reconstruction by means of a heavy Marlex-mesh circumferential graft covered with a free autologous pericardial flap. Neville and his co-workers [17] reported resection of the entire intrathoracic trachea and both main bronchi in a patient with severe airway obstruction due to an adenoid cystic carcinoma. Tracheobronchial reconstruction was accomplished during cardiopulmonary bypass by means of a bifurcated Silastic graft. The use of extracorporeal circulation in tracheal resection has been advocated by Neville and his associates [18] and Adkins and Izawa [l]. We believe the combination of tracheal prosthesis and extracorporeal circulation is not indicated in most cases of tracheal tumor. However, in patients with serious obstruction of the tracheobronchial tree in whom the tracheal tumor is extensive, the use of cardiopulmonary bypass and a tracheal prosthesis might be indicated. An early diagnosis and aggressive surgical ap- 566 THE ANNALS OF THORACIC SURGERY

13 Tracheal Obstruction proach to tumors of the trachea will significantly improve the long-term results in terms of palliation and cure. References 1. Adkins, P. C., and Izawa, E. M. Resection of tracheal cylindroma using cardiopulmonary by-pass. Arch. Surg. 88:405, Andrews,,M. J., and Pearson, F. G. Incidence and pathogenesis of tracheal injury following ed tube tracheostomy with assisted ventilation. Ann. Surg. 173:249, Beall, A. C., Jr., Brewster, O., Harrington, 0. B., Greenberg, S. D., Morris, G. C., and Usher, F. C. Tracheal replacement with heavy Marlex mesh. Arch. Surg. 86:970, Clark, P. L., Clagett, 0. T., and MacDonald, J. R. Cylindroma of the trachea. Proc. Stag Meet. Mayo Clin. 28:513, Cooper, J. D., and Grillo, H. C. The evolution of tracheal injury due to ventilatory assistance through ed tubes: A pathologic study. Ann. Surg. 169:334, Falbe-Hansen, J. On the treatment of tracheal stenosis in tracheotomized polio patients. Acta Otolaryngol. 45:498, Fishman, N. H., Dedo, H. H., Hamilton, W. K., Hinchcliffe, W. A., and Roe, B. B. Postintubation tracheal stenosis. Ann. Thorac. Surg. 8:47, Grillo, H. C. The management of tracheal stenosis following assisted respiration. J. Thorac. Cardiovasc. Surg. 57:52, Grillo, H. C. Surgical approaches to the trachea. Surg. Gynecol. Obstet. 129:347, Grillo, H. C. Tracheal surgery. Curr. Probl. Surg., July, P Grillo, H. C., Cooper, J. D., Geffin, B., and Pontoppidan, H. A low-pressure for tracheostomy tubes to minimize tracheal injury: A comparative clinical trial. J. Thorac. Cardiovasc. Surg , Hadju, S. J., Huvos, A. G., Goodner, J. T., Foote, F. W., Jr., and Beattie, E. J., Jr. Carcinoma of the trachea: Clinicopthologic study of 41 cases. Cancer 25: 1448, Houston, H. E., Spencer, P., Harrison, E. G., Jr., and Olsen, A. M. Primary cancers of the trachea. Arch. Surg. 99:132, Houston, I. B., and Mackie, D. G. Congenital tracheal stenosis.. Thorax 16:94, Johnston, J. B., Wright, J. S., and Hercus, V. Tracheal stenosis following tracheostomy: A conservative approach to treatment. J. Thorac. Cardiovasc. Surg. 53:206, Mulliken, J. B., and Grillo, H. C. The limits of tracheal resection with primary anastomosis: Further anatomical studies in man. J. Thorac. Cardiovasc. Surg. 55:418, Neville, W. E., Hamouda, F., Andersen, J., and Dwan, F. M. Replacement of the intrathoracic trachea and both stem bronchi with a molded Silastic prosthesis. J. Thorac. Cardiooasc. Surg. 63:569, Neville, W. E., Langston, H. T., Correll, N., and Maben, H. Cardiopulmonary by-pass in pulmonary surgery. J. Thorac. Cardiovasc. Surg. 50:265, Yeh, T. H., Batayias, G., Peters, H., and Ellison, R. G. Metastatic carcinoma to the trachea: A report of a case of palliation by resection and Marlex graft. J. Thorac. Cardiovasc. Surg. 49:886, VOL. 16, NO. 6, DECEMBER,