Development of tracheal surgery: a historical review. Part 1: Techniques of tracheal surgery.
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History, 16th Century↗
Biomedical subjects
Hermes C Grillo
Publications and source records attributed to Hermes C Grillo.
Development of tracheal surgery: a historical review. Part 2: Treatment of tracheal diseases.
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History, 18th Century↗
Infectious necrotizing esophagitis: outcome after medical and surgical intervention.
BACKGROUND: Immunodeficiency predisposes to invasive esophageal infections. The treatment of perforation, respiratory fistula, and necrosis due to transmural esophageal infection is guided by anecdote. We wish to determine treatment and outcome of local complications of necrotizing esophagitis. METHODS: We report our experience over a 7-year period and review published reports since 1976. We treated 4 patients and found 21 reported patients with perforation (11/25), fistula (8/25), and necrosis (6/25) at a mean age of 35 years. Twenty-one patients were immunodeficient (84%) due to acquired immunodeficiency syndrome in 8, acute leukemia in 6, renal transplant in 3, diabetes mellitus, renal failure, and corticosteroids in 1 each. Pathogenic organisms were fungal in 15 cases, viral in 7, and bacterial in 7. RESULTS: Treatment consisted of antibiotic therapy in 13 patients and surgical intervention combined with antibiotic therapy in 12: esophagectomy in 6, esophageal stenting and drainage in 2, drainage alone in 2, and salivary diversion in 2. Overall mortality was 48% (12/25). Mortality without surgical intervention was 90% (9/10) and with surgical intervention 27% (3/11). One of 6 patients undergoing esophagectomy (17%) died. The difference in mortality was due to sepsis, which was the cause of death in 8 patients treated with medical intervention and only 1 treated with surgical intervention. CONCLUSIONS: Local complications of necrotizing esophagitis have a high mortality due to sepsis. Surgical intervention, in particular esophagectomy, controls sepsis in published case reports and should be considered in selected patients. Further study is required to determine the true prevalence of these complications and the outcome of intervention.
Adult↗
The surgical approach to "dumbbell tumors" of the mediastinum.
BACKGROUND: Successful management of posterior mediastinal dumbbell tumors depends on complete resection with adequate exposure. Correct preoperative assessment of neuroforaminal extension is important to avoid spinal cord injury. The surgical approach remains controversial. METHODS: We report a retrospective analysis of posterior mediastinal dumbbell tumors over a 28-year period. All patients underwent one or more radiographic examinations available at the time of presentation and underwent a single-stage one-incision combined thoracic and neurosurgical procedure. RESULTS: Among 16 patients aged 5 to 76 years, neuroforaminal involvement was identified before operation in 14 (87.5%) and during the procedure in 2 patients (12.5%). Computed tomography scan missed neuroforaminal involvement in 3 patients. Magnetic resonance imaging in 9 patients correctly identified neuroforaminal extension of the tumor but before MRI, myelography missed this extension in 3 patients. All patients underwent thoracotomy and posterior laminectomy was required in 10 of them. In 6 patients (38%) without laminectomy, resection required widening of the neural foramen in 3 whereas tumor was removed in 3 others through an already widened foramen. Spinal stabilization was required in 2 patients. There were 14 benign and 2 malignant lesions. Complete resection was performed in all patients without spinal cord injury or other major complication. No recurrences have been observed in a follow-up period from 2 months to 28 years (mean, 7.5 years). CONCLUSIONS: Posterior mediastinal tumors should be evaluated for neuroforaminal involvement. A single-stage combined thoracic and neurosurgical approach is safe and leads to good long-term results. Laminectomy may be avoided in some patients.
Adolescent↗
Complication of benign tracheobronchial strictures by self-expanding metal stents.
OBJECTIVES: Self-expanding metal stents are used to palliate benign strictures. We examined the complications of this approach. METHODS: Between 1997 and 2002, we observed recurrent airway obstruction and extension of benign inflammatory strictures after the placement of tracheobronchial Microvasive Ultraflex stents and Wallstents (Boston Scientific Corp, Natick, Mass), in 10 patients with postintubation strictures and 5 with other indications; all but 1 patient were referred to us. Patients with tracheal (9), subglottic (1), combined tracheal and subglottic (3), and bronchial (2) strictures had been treated with covered and uncovered Wallstents (6) and Microvasive Ultraflex stents (9). RESULTS: After stent insertion, stricture and granulations within previously normal airway were seen in all patients. New subglottic strictures resulting from the stent caused hoarseness in 4 patients. A bronchoesophageal fistula was found in 1 patient at presentation and a tracheoesophageal fistula in another during extraction of a Wallstent. Primary surgical reconstruction, judged to have been feasible before wire stent insertion in 10 patients, was possible after stenting in only 7 and failed in 2. Palliative tubes were placed in 60% (9/15). Self-expanding metal stents may lengthen luminal damage, incite subglottic strictures, and cause esophagorespiratory fistula in inflammatory airway strictures. The injury is severe, occurs after a short duration of stenting, and precludes definitive surgical treatment or requires more extensive tracheal resection. CONCLUSION: The current generation of self-expanding metal stents should be avoided in benign strictures of trachea and bronchi.
Adult↗
The history of tracheal surgery.
Tracheal surgery, which did not exist in a coherent, systematic fashion 45 years ago, has developed techniques that allow resection of approximately half of the adult trachea with primary reconstruction, largely by anatomic mobilization procedures. Dependable methods have also been developed for laryngotracheal and carinal resection and reconstruction. The daunting problem of long congenital tracheal stenosis appears to be largely solved by slide tracheoplasty. In the past four decades much has also been learned about the etiology, natural history, pathology, and (in some cases) prevention of tracheal diseases including primary and secondary tumors, postintubation injuries, and idiopathic stenosis.
History, 20th Century↗
Omentum is highly effective in the management of complex cardiothoracic surgical problems.
OBJECTIVES: Vascularized, pedicled tissue flaps are often used for cardiothoracic surgical problems complicated by factors that adversely affect healing, such as previous irradiation, established infection, or steroid use. We reviewed our experience with use of the omentum in these situations to provide a yardstick against which results with other vascularized flaps (specifically muscle flaps) could be compared. METHODS: A retrospective review was undertaken of 85 consecutive patients in whom omentum was used in the chest. In 47 patients (group I), use of omentum was prophylactic to aid in the healing of closures or anastomoses considered to be at high risk for failure. In 32 patients (group II), omentum was used in the treatment of problems complicated by established infection. In 6 patients (group III), omentum was used for coverage of prosthetic chest wall replacements after extensive chest wall resection. RESULTS: Overall, omental transposition was successful in its prophylactic or therapeutic purpose in 88% of these difficult cases (75/85). Success with omentum was achieved for 89% of patients (42/47) in group I, 91% of patients (29/32) in group II, and 67% of patients (4/6) in group III. Three patients (3.5%) had complications of omental mobilization. Four patients (4.7%) died after the operation as a result of failure of the omentum to manage the problem for which it was used. CONCLUSIONS: Results with omental transposition compare favorably with published series of similarly challenging cases managed with muscle transposition. Complications of omental mobilization are rare. We believe that its unique properties render the omentum an excellent choice of vascularized pedicle in the management of the most complex cardiothoracic surgical problems.
Cardiac Surgical Procedures↗
Successful treatment of idiopathic laryngotracheal stenosis by resection and primary anastomosis.
We studied the early and long-term response of idiopathic laryngotracheal stenosis (ILTS) to treatment by 1-stage laryngotracheal or tracheal resection and reconstruction in 73 patients. Nineteen of the 72 (26%) noted no difference in their voices or any difficulty in breathing after reconstruction. Forty-seven (64%) described loss of ability to project their voices as loudly as before or noted some difficulty in singing as well as they did before. Five (7%) had various degrees of dyspnea or stridor on effort. One needed continued dilation. The median follow-up was 8 years. Surgical treatment gave good or excellent results in 90% of these patients with ILTS. Recurrence or progression of stenosis was not evident.
Adolescent↗
Benign broncho-esophageal fistula in the adult.
BACKGROUND: Benign broncho-esophageal fistula (BEF) in the adult is rare, and occurs as a complication of inflammatory disorders, foreign body ingestion, or congenital anomalies. Nonspecific symptoms lead to a delay in diagnosis. METHODS: The charts of 13 patients from 1960 to 2001 at the Massachusetts General Hospital were retrospectively reviewed. RESULTS: Nine patients had chronic cough, which worsened upon ingestion. Four patients developed BEF after prior thoracic surgery, and 3 after histoplasmosis. Silicosis, foreign body ingestion, lye ingestion, bronchogenic cyst, esophageal diverticulum, and a congenital anomaly caused BEF in 1 patient each. Barium swallow was the most useful diagnostic test. Fistulas most often arose from the right bronchial tree and communicated with the distal esophagus. Management involved excision of the tract, primary closure of the bronchus and esophagus, and interposition of vascularized tissue. There was one perioperative failure, but no long-term recurrences after successful surgical closure. CONCLUSIONS: The majority of benign BEF in adults are acquired, and result from mediastinal inflammation. Accurate recognition and surgical closure prevents persistent uncontrolled aspiration and pulmonary sepsis.
Adolescent↗
Induction chemoradiation compared with induction radiation for lung cancer involving the superior sulcus.
BACKGROUND: The usual approach of induction radiation therapy (RT) followed by resection of superior sulcus tumors results in many incomplete resections, a high local recurrence rate, and suboptimal survival. Induction chemoradiotherapy (CT/RT) has been shown to reduce local and distant recurrences and improve survival in stage III lung cancer. We investigated the role of induction CT/RT in superior sulcus patients. METHODS: This was a single-institution, retrospective study. RESULTS: From 1985 to 2000, 35 consecutive patients underwent induction treatment followed by resection of a superior sulcus tumor. All patients had mediastinoscopy first to exclude N2 disease, and all were N0 at final pathologic examination. Twenty patients had induction RT (mean, 39 Gy), and 15 had induction CT/RT (mean, 51 Gy) with concurrent cisplatin-based chemotherapy. There was no treatment mortality. Complete resection was performed in 16 of 20 (80%) of the RT patients and in 14 of 15 (93%) of the CT/RT patients (p = 0.15). The pathologic response from the induction treatment was complete or near complete in 7 of 20 (35%) of the RT patients and in 13 of 15 (87%) of the CT/RT patients (p = 0.001). The median follow-up was 167 months in the RT patients and 51 months in the CT/RT patients. Two-year and 4-year survival was 49% and 49% (95% confidence interval, 26% to 71%) in the RT patients and 93% and 84% (95% confidence interval, 63% to 100%) in the CT/RT patients, respectively (p = 0.01). The local recurrence rate was 6 of 20 (30%) in the RT patients and 0 in the CT/RT patients (p = 0.02). CONCLUSIONS: Induction CT/RT for superior sulcus tumors appears to offer improved survival compared with induction RT alone.
Adult↗
Tracheal replacement: a critical review.
This review discusses the need for tracheal replacement, distinct from resection with primary anastomosis, the requirements for replacement, and the many efforts over the past century to accomplish this goal experimentally and clinically. Approaches have included use of foreign materials, nonviable tissue, autogenous tissue, tissue engineering, and transplantation. Biological problems in each category are noted.
Bioprosthesis↗
Pediatric tracheal surgery.
BACKGROUND: Pediatric tracheal procedures are uncommon. We reviewed our experience to clarify management and results. METHODS: Retrospective single-institution review of pediatric tracheal operations, 1978 to 2001. RESULTS: One hundred sixteen children were evaluated, mean age 10.4 years (10 days to 18 years). Tracheal pathology was postintubation stenosis (n = 72; 62%), congenital stenosis (n = 23; 20%), neoplasm (n = 8; 7%), tracheomalacia (n = 7; 6%), and trauma (n = 6; 5%). Twenty-nine patients had previous tracheal operations. Thirty-six patients received only a minor procedure. Eighty patients had major operations: tracheal resection (n = 46; 58%), laryngotracheal resection (n = 22; 28%), slide tracheoplasty (n = 7; 9%), and carinal resection (n = 5; 6%). The mean length of airway resected was 3.3 cm (1.5 to 6 cm), which represented 30% of the entire trachea. Twenty-eight patients (35%) had complications. These included tracheomalacia (n = 3), recurrent nerve injury (n = 3), laryngeal edema requiring intubation (n = 2), stroke (n = 1), esophageal leak (n = 1), and lobar collapse (n = 1). Nineteen patients had anastomotic failure: severe restenosis (n = 6), mild restenosis (n = 9), dehiscence (n = 2), dehiscence with tracheoesophageal fistula (n = 1), and tracheoinnominate fistula (n = 1). Two children died (2.5%). Complications were more frequent in children less than 7 years of age (p = 0.05) and after previous operations (p = 0.02). Longer fractions of tracheal resection (> 30%) were more likely to result in anastomotic failure (p = 0.0005). Sixty-four (80%) patients achieved a stable airway free of any airway appliance. All patients with neoplasms are alive. CONCLUSIONS: The principles of adult tracheal operations are directly applicable to children and usually lead to a stable, satisfactory airway. Children tolerate anastomotic tension less well than adults; resections more than 30% have a substantial failure rate.
Adolescent↗
Adjuvant radiation therapy for stage II thymoma.
BACKGROUND: Thymoma is difficult to study because of its indolent natural history. The criteria for administration of adjuvant radiation therapy remain controversial, and it is unclear whether patients with Masaoka stage II thymoma benefit from adjuvant radiation. The goal of this report was to determine whether or not this group benefits from radiation therapy in terms of disease-specific survival and tumor recurrence. METHODS: Case records of the Massachusetts General Hospital were retrospectively reviewed from 1972 to 1999. One hundred fifty-five patients underwent resection for thymoma, of which, 49 had stage II disease. The world literature was reviewed using a Medline search (1966 to 2001), and a secondary review of referenced works was performed. RESULTS: Fourteen stage II patients underwent radiation therapy. Thirty-five did not receive radiation therapy. Baseline prognostic factors between radiated and nonradiated groups were similar. All patients underwent complete resection. The addition of adjuvant radiotherapy did not significantly alter local or distant recurrence rates in stage II thymoma. Disease-specific survival at 10 years in stage II patients was 100% with radiotherapy and without radiotherapy (p = 0.87). There was one recurrence in the nonradiated group at 180 months, which was outside the usual radiation portal. CONCLUSIONS: Most stage II patients do not require adjuvant radiation therapy and can be observed after complete resection.
Adolescent↗
Management of congenital tracheal stenosis by means of slide tracheoplasty or resection and reconstruction, with long-term follow-up of growth after slide tracheoplasty.
OBJECTIVE: The difficult problem of congenital tracheal stenosis is infrequent and has been managed with several methods. Patch tracheoplasty has been favored in recent years. Alternative experience with a simpler program of slide tracheoplasty for long-segment stenosis or resection and reconstruction for short-segment stenosis is described and proposed as preferable. Long-term growth after slide tracheoplasty was studied. METHODS: Eleven consecutive patients aged 10 days to 23 years with varied patterns of stenosis (including concurrent pulmonary artery sling, anomalous right upper lobe bronchus, and bridge bronchus) had their stenoses corrected, 8 by means of slide tracheoplasty and 3 by means of resection and anastomosis. Retrospective review was made of hospital course, complications, and long-term results, with observation of growth in 4 patients (from more than 1(1/2)-7(3/4) years). RESULTS: All patients are alive and enjoy good airways. Only 3 patients who needed concomitant cardiovascular procedures and 1 with poor ventricular function required bypass. Eight were extubated immediately or on the day of the operation, 1 at 3 days, and 1 at 8 days. A patient with complex anomalies needed 10 days of ventilation. Three had anastomotic granulomas successfully treated by means of a single bronchoscopy. Long-term airway growth was entirely satisfactory after slide tracheoplasty in 4 infants and small children (aged 10 days, 3 months, 6 months, and 3(1/2) years, respectively). CONCLUSIONS: Slide tracheoplasty gives excellent short- and long-term results because long congenital stenosis is reconstructed with native tracheal tissue and is therefore immediately stable and lined with normal epithelium, and the operation is accomplished more simply and with a generally more benign postoperative course. Wholly satisfactory growth of the repaired segment occurs. Less common short congenital stenosis is effectively managed with resection and anastomosis.
Adolescent↗