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Tracheal resection: the team brief in multi-stage airway surgery.

ABSTRACT: The multidisciplinary team brief and effective clinical decision-making are critical to airway surgery. To illustrate this, we present the case of a 58-year-old female with papillary thyroid cancer invading the trachea. We describe a basic framework that was used to aid planning the management of this patient. Tracheal resection is a complex airway operation requiring the evaluation of airway obstruction risk, the formulation of strategies for complex airway management and lung ventilation during complete resection of the tracheal segment and a handover plan for safe tracheal extubation. We suggest that team performance is facilitated by a standardised structure for consideration of anticipated events and important decisions to be made before the operation. Furthermore, it can provide a platform to engage the team when unanticipated events occur and alternate plans have to be made in a time-critical manner.

SUBMITTER: Cervi E

PROVIDER: S-EPMC7084112 | biostudies-literature | 2020 Jan-Jun

REPOSITORIES: biostudies-literature

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Tracheal resection: the team brief in multi-stage airway surgery.

Cervi E E Ong C C

Anaesthesia reports 20200101 1

The multidisciplinary team brief and effective clinical decision-making are critical to airway surgery. To illustrate this, we present the case of a 58-year-old female with papillary thyroid cancer invading the trachea. We describe a basic framework that was used to aid planning the management of this patient. Tracheal resection is a complex airway operation requiring the evaluation of airway obstruction risk, the formulation of strategies for complex airway management and lung ventilation durin ...[more]

PMID: 32211609

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Project description:BackgroundBenign airway stenoses are complex disorders that present with progressive dyspnoea, stridor, and significant respiratory distress. These conditions have a high recurrence rate and despite the plethora of endoscopic and open techniques available for treatment, the outcomes are variable. Our primary was to determine the pre-operative factors associated with an increased hazard of cricotracheal resection (CTR)/tracheal resection (TR) and reconstruction in cases of benign subglottic and tracheal strictures.MethodsWe performed a retrospective analysis of a prospectively maintained database of all patients ages 16 years and over with benign subglottic and tracheal stenoses that underwent endoscopic or surgical treatment at our institution between 2008 and 2022.ResultsNinety-seven patients were included in our series, with a strong female preponderance (n=79; 81%). Forty-one patients underwent formal resection and reconstruction, and 56 patients were managed conservatively. Subglottic stenosis (SGS) was the most common site of disease in the trachea (79%), and the common aetiology of all stenoses was idiopathic (52%). The median interval between first dilatation and formal resection was 5 [interquartile range (IQR), 0-173] months. Pre-operative tracheostomy rate was significantly higher in those who underwent TR (51% vs. 18%, P<0.001) yet the number of dilatations was equivocal between the surgical and non-surgical groups (P=0.30). The most significant independent predictors of TR were pre-operative tracheostomy, advanced Myer-Cotton grading and an increased number of involved airway subsites. Risk modelling using these parameters identified a low and a high-risk group for TR and the latter had a significantly reduced time to resection (P<0.001).ConclusionsBenign airway stenoses are a heterogeneous group of conditions which respond to both endoscopic and open surgical airway intervention. The underlying aetiology will influence the treatment paradigm. We found that more complex lesions, patients with pre-operative tracheostomy and previous smoking history conferred a higher hazard for resection.

Project description:IntroductionThe primary cause of death in Morquio A syndrome (mucopolysaccharidosis (MPS) IVA) is airway obstruction, brought about by an inexorable and pathognomonic multilevel airway tortuosity, buckling, and obstruction. The relative pathophysiological contributions of an inherent cartilage processing defect versus a mismatch in longitudinal growth between the trachea and the thoracic cage are currently a subject of debate. Enzyme replacement therapy (ERT) and multidisciplinary management continue to improve life expectancy for Morquio A patients by slowing many of the multisystem pathological consequences of the disease but are not as effective at reversing established pathology. An urgent need has developed to consider alternatives to palliation of progressive tracheal obstruction to preserve and maintain these patients' hard-won good quality of life, as well as to facilitate spinal and other required surgery. Case Report. Following multidisciplinary discussion, transcervical tracheal resection with limited manubriectomy was successfully performed, without the need for cardiopulmonary bypass, in an adolescent male on ERT with the severe airway manifestations of Morquio A syndrome. His trachea was found to be under significant compressive forces at surgery. On histology, chondrocyte lacunae appeared enlarged, but intracellular lysosomal staining and extracellular glycosaminoglycan staining was comparable to control trachea. At 12 months, this has resulted in a significant improvement in respiratory and functional status, with corresponding enhancement to his quality of life.ConclusionThis addressing of tracheal/thoracic cage dimension mismatch represents a novel surgical treatment approach to an existing clinical paradigm and may be useful for other carefully selected individuals with MPS IVA. Further work is needed to better understand the role and optimal timing of tracheal resection within this patient cohort so as to individually balance considerable surgical and anaesthetic risks against the potential symptomatic and life expectancy benefits.

Project description:BackgroundMucopolysaccharidosis (MPS) type IVA is a rare lysosomal storage disorder caused by aberrations of the N-acetyl-galactosamine-6-sulfatase (GALNS) enzyme. MPS IVA is associated with a wide gamut of respiratory and airway disorders that manifest in a continuum of severity. In individuals exhibiting severe phenotypic expression, terminal stages of the disease frequently culminate in life-threatening, critical airway obstruction. These manifestations of end-stage disease are engendered by an insidious progression of multi-level airway pathologies, comprising of tracheomalacia, stenosis, tortuosity and 'buckling'. Historically, the management of end-stage airway disease has predominantly leaned towards palliative modalities. However, contemporary literature has posited that the potential benefits of tracheal resection with aortopexy, performed under cardiopulmonary bypass (CPB), may offer a promising therapeutic option. In this context, we report on outcomes from patients undergoing a novel approach to tracheal resection that is combined with manubrial resection, leading to improved airway calibre, obviating the requisition for CPB.ResultsIn this study, seven patients with severe MPS IVA exhibited clinical symptoms and radiological evidence indicative of advanced airway obstruction. All patients had a tracheal resection with a partial upper manubriectomy via transcervical approach, which did not require CPB. The surgical cohort consisted of 5 females and 2 males, the median age was 16 years (range 11-19) and the median height was 105.6cm (range 96.4-113.4). Postoperatively, significant improvements were seen in forced expiratory volume in 1 second (FEV1), with a mean increase of 0.68 litres (95% CI: 0.45-0.91; SD: 0.20). Notably, other spirometry variables also showed meaningful improvements, providing evidence of positive treatment effects. Furthermore, there were no major long-term complications, and the procedure resulted in a significant enhancement in patient-reported domains using PedsQL (version 4.0).ConclusionsThis study represents the largest case series to date, on tracheal resection in patients with severe MPS IVA. Our findings demonstrate the effectiveness of the transcervical approach with partial manubriectomy for improving respiratory function and quality of life for individuals with advanced airway obstruction. Tracheal resection presents a promising treatment modality for severe cases of MPS IVA. Successful outcomes rely on meticulous multidisciplinary assessment, judicious decision-making, and appropriate timing of tracheal surgery. Further research and long-term follow-up studies are warranted to validate the long-term efficacy and safety of this approach.

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Tracheal resection: the team brief in multi-stage airway surgery.

Publications

Tracheal resection: the team brief in multi-stage airway surgery.

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