HOW TO DO IT
Controlled Trachea Suspension for Tracheomalacia After Resection of Large Anterior Mediastinal Mass Zhengcheng Liu, MD, Rusong Yang, MD, Feng Shao, MD, and Yanqing Pan, MD Department of Thoracic Surgery, Nanjing Chest Hospital Affiliated With Southeast University, Nanjing, China
Tracheomalacia is a disorder of the large airways that is often caused by a large anterior mediastinal mass. This study describes 7 patients who underwent controlled trachea suspension as a surgical intervention to prevent severe tracheomalacia and provide potent relief of airway symptoms. All patients recovered well. The results
demonstrate this procedure may be safe and effective for resection of a large mediastinal mass compressing the trachea with collapsed segments.
T
sternotomy (6 of 7 patients). After surgical removal of the compression, the extent of underlying malacia was assessed. The airway was visually inspected and manually palpated in the surgical field, and it was also evaluated by bronchoscope. An endotracheal tube positioned over the compressed segment, and the compressive effects of expiration were simulated by applying suction to the airway through the bronchoscope under the passive conditions of general anesthesia. If a malacic segment was discovered, trachea suspension was performed. Using 3-0 Prolene (Ethicon, Somerville, NJ) sutures, we grasped and elevated the anterior fascia while bronchoscopy was simultaneously performed to define the region of maximal malacia precisely and choose optimal points for suture placement. The 3-0 Prolene vertical sutures were placed through the anterior tracheal fascia through two cartilage rings to avoid penetrating into the lumen of the trachea (Fig 2). Under bronchoscopic guidance, tension was placed while the sutures were elevated to demonstrate the positive effect and to ensure optimal placement. Once the sutures were adjusted and finalized in position, they were passed through a free pledget without tying. The sutures were then sequentially passed through the sternal plate and were twisted around a retention bar (Fig 3). Bronchoscopy was performed as the sternum was brought together. The sutures were dragged and tightened under continuous bronchoscopic guidance. Care was taken to provide adequate anterior suspension without creating distortion. The sutures were retained for at least 7 days postoperatively. If patients recovered without impaired breathing and coughing, the sutures were loosened by slipping the knotted suture over the retention bar. If symptoms of dyspnea, stridor, or wheezing appeared, the sutures were tightened to suspend the trachea. If no sign of upper airway obstruction or trachea collapse was seen on chest CT and bronchoscopy when the sutures were completely loose, the controlled suspension sutures were removed.
Technique Between 2010 and 2013, 7 patients with large anterior mediastinal masses were observed and treated at our institution. The database was queried to identify all patients who underwent CTS. Informed consent for participation in the study and the procedure was obtained from the patients by telephone. All patients underwent a functional study with measurement of levels of free triiodothyronine, free thyroxine, thyroid-stimulating hormone, thyroglobulin, antibodies against thyroperoxidase and thyroglobulin, and parathyroid hormone. Neck and chest computed tomography (CT) and magnetic resonance imaging for preoperative surgical planning were performed in all cases (Fig 1). Valsalva-Mueller tests confirmed tracheomalacia. Preoperative and postoperative bronchoscopy was performed to assess vocal cord function and the dynamic pattern of airway collapse and to evaluate postoperative status in these patients. The surgical procedures were performed by an experienced surgical team. The patients were intubated in the supine position, and they had either a limited vertical midline incision (1 of 7 patients) or a full median Accepted for publication Jan 27, 2015. Address correspondence to Dr Rusong, Department of Thoracic Surgery, Nanjing Chest Hospital, Guangzhou Rd 215, Nanjing, Jiangsu Province, 210029, China; e-mail: [email protected].
Ó 2015 by The Society of Thoracic Surgeons Published by Elsevier
0003-4975/$36.00 http://dx.doi.org/10.1016/j.athoracsur.2015.01.067
FEATURE ARTICLES
racheomalacia is a disorder of the large airways that is often caused by a large anterior mediastinal mass [1], which results in a spectrum of respiratory symptoms ranging from chronic cough to life-threatening apnea and airway obstruction. Several interventions described have limitations, and a definitive solution does not exist. This study describes 7 patients who underwent controlled trachea suspension (CTS) as a surgical intervention to prevent severe tracheomalacia and provide potent relief of airway symptoms in severe cases.
(Ann Thorac Surg 2015;99:2225–7) Ó 2015 by The Society of Thoracic Surgeons
2226
HOW TO DO IT LIU ET AL TRACHEA SUSPENSION FOR TRACHEOMALACIA
Fig 1. Chest computed tomography shows tracheal compression with narrowing of the lumen.
FEATURE ARTICLES
Results Seven patients (5 men and 2 women) with a median age of 54 years (range, 34 to 73 years) underwent CTS; this group comprised 4.5% (7 of 155) of all mediastinal tumors resected. The presentation for compressive symptoms was the reason for first access to medical care. All patients had tracheomalacia diagnosed by flexible bronchoscopy. Preoperative CT scans with three-dimensional airway reconstruction were performed to define the anatomic features and the severity of disease. The mean surgical time was 133.4 minutes (range, 76 to 218 minutes). Pathologic examination of gross specimens showed a mean weight of 891 g (range, 504 to 1830 g) with a mean diameter of 14.5 cm (range, 12.2 to 17.5 cm). Histologic examination demonstrated substernal mediastinal goiter in 3 patients, thymoma in 3 patients, and thymic carcinoma in 1 patient.
Ann Thorac Surg 2015;99:2225–7
Fig 3. The sutures are then sequentially passed through the sternal plate and twisted around a tension suture plate.
All patients were mechanically ventilated after the surgical procedure for 8 to 48 hours, and they were successfully extubated. No patient required continuous positive airway pressure or suffered acute lifethreatening events. Four patients developed dyspnea immediately to 3 hours after the suspension sutures were released, and they recovered after the dragging sutures were tightened. Additional attempts to release the sutures were made every second day. One patient underwent two attempts and recovered without suspension sutures, 2 patients underwent two attempts, and 1 patient underwent three attempts. No permanent recurrent laryngeal nerve palsy occurred. All patients survived and were discharged, with a median total length of stay of 25 days (range, 14 to 29 days) and a median postsurgical length of stay of 14 days (range, 10 to 16). Median follow-up time was 12 months (range, 5 to 36 months). These patients recovered without complications or other notable events, signs of tumor recurrence, or metastasis. Pulmonary function tests were performed 6 months after the surgical procedure; the mean ratio of forced expiratory volume in 1 second to forced vital capacity (FEV1/FVC) was 87.7% (range, 69.5% to 105.9%), and the mean maximum voluntary ventilation was 84.4 L/minute (range, 59.5 to 97.9 L/minute).
Comment
Fig 2. The 3-0 Prolene (Ethicon, Somerville, NJ) vertical sutures are placed through the anterior tracheal fascia through two cartilage rings.
Any cervical or mediastinal lesion compressing the trachea could lead to tracheomalacia by compromising the blood and nutrient flow to the supporting cartilage, with resulting postoperative softening and collapse of the trachea wall [2, 3]. Tracheomalacia should be intensively considered. The extent of underlying malacia secondary to chronic tracheal compression cannot be assessed until surgical removal of the extrinsic compression [4]. The compressive effects could be simulated by applying suction to the airway through the bronchoscope. Judgment regarding management must be made when a malacic segment is discovered. If the segment is completely devoid of structural cartilage and is severely malacic, tracheal suspension is indicated. Otherwise, mild to moderate
Ann Thorac Surg 2015;99:2225–7
malacia can be retained without attempting surgical correction. Endotracheal suspension, tracheotomy, and tracheal stents are possible surgical options. However, hemorrhage, wound infection, decannulation, tracheal stenosis, and other complications may be associated with these procedures, thus indicating that less traumatic manipulation should be considered [5, 6]. CTS provides specific support to the affected region and produces an impressive direct effect on the anterior cartilage. Caution must be taken to avoid distortion of the airway as a result of excessive tension on the sutures. Careful assessment must be made to ensure safe pathways for the suspension sutures. Sutures should not penetrate whole trachea layers, to avoid mediastinal infection or emphysema caused by air leakage. A retention bar could provide better support for sutures and cause less harm to the tissue around the sutures because of its high strength and low pressure on skin. Twisted to a retention bar, suspension sutures are tightly fastened, and they could be easily loosened. Several days after the surgical procedure, when the trachea adheres to the surrounding tissue, sutures could be loosened. If no signs of trachea collapse are observed, the sutures and bar could be removed; otherwise, sutures should be tightly fastened again if stridor or other symptoms
HOW TO DO IT LIU ET AL TRACHEA SUSPENSION FOR TRACHEOMALACIA
2227
related to trachea collapse occur until tracheal rings provide enough strength for breathing. Currently, we perform CTS in all patients with severe tracheomalacia who are candidates for tracheostomy or chronic ventilator support, and these patients are functioning well postsurgically. The findings of this report suggest that CTS may be safe and effective with little postoperative discomfort, and it should be considered to treat tracheomalacia after resection of a large anterior mediastinal mass.
References 1. Kugler C, Stanzel F. Tracheomalacia. Thorac Surg Clin 2014;24:51–8. 2. Vasko JS, Ahn C. Surgical management of secondary tracheomalacia. Ann Thorac Surg 1968;6:269–72. 3. Cogbill TH, Moore FA, Accurso FJ, Lilly JR. Primary tracheomalacia. Ann Thorac Surg 1983;35:538–41. 4. Cho JH, Kim HJ, Kim J. External tracheal stabilization technique for acquired tracheomalacia using a tailored silicone tube. Ann Thorac Surg 2012;94:1356–8. 5. Mitchell ME, Rumman R, Chun RH, et al. Anterior tracheal suspension for tracheobronchomalacia in infants and children. Ann Thorac Surg 2014;98:1246–53. 6. Carden KA, Boiselle PM, Waltz DA, Ernst A. Tracheomalacia and tracheobronchomalacia in children and adults: an indepth review. Chest 2005;127:984–1005.
FEATURE ARTICLES
Controlled Trachea Suspension for Tracheomalacia After Resection of Large Anterior Mediastinal Mass Zhengcheng Liu, MD, Rusong Yang, MD, Feng Shao, MD, and Yanqing Pan, MD Department of Thoracic Surgery, Nanjing Chest Hospital Affiliated With Southeast University, Nanjing, China
Tracheomalacia is a disorder of the large airways that is often caused by a large anterior mediastinal mass. This study describes 7 patients who underwent controlled trachea suspension as a surgical intervention to prevent severe tracheomalacia and provide potent relief of airway symptoms. All patients recovered well. The results
demonstrate this procedure may be safe and effective for resection of a large mediastinal mass compressing the trachea with collapsed segments.
T
sternotomy (6 of 7 patients). After surgical removal of the compression, the extent of underlying malacia was assessed. The airway was visually inspected and manually palpated in the surgical field, and it was also evaluated by bronchoscope. An endotracheal tube positioned over the compressed segment, and the compressive effects of expiration were simulated by applying suction to the airway through the bronchoscope under the passive conditions of general anesthesia. If a malacic segment was discovered, trachea suspension was performed. Using 3-0 Prolene (Ethicon, Somerville, NJ) sutures, we grasped and elevated the anterior fascia while bronchoscopy was simultaneously performed to define the region of maximal malacia precisely and choose optimal points for suture placement. The 3-0 Prolene vertical sutures were placed through the anterior tracheal fascia through two cartilage rings to avoid penetrating into the lumen of the trachea (Fig 2). Under bronchoscopic guidance, tension was placed while the sutures were elevated to demonstrate the positive effect and to ensure optimal placement. Once the sutures were adjusted and finalized in position, they were passed through a free pledget without tying. The sutures were then sequentially passed through the sternal plate and were twisted around a retention bar (Fig 3). Bronchoscopy was performed as the sternum was brought together. The sutures were dragged and tightened under continuous bronchoscopic guidance. Care was taken to provide adequate anterior suspension without creating distortion. The sutures were retained for at least 7 days postoperatively. If patients recovered without impaired breathing and coughing, the sutures were loosened by slipping the knotted suture over the retention bar. If symptoms of dyspnea, stridor, or wheezing appeared, the sutures were tightened to suspend the trachea. If no sign of upper airway obstruction or trachea collapse was seen on chest CT and bronchoscopy when the sutures were completely loose, the controlled suspension sutures were removed.
Technique Between 2010 and 2013, 7 patients with large anterior mediastinal masses were observed and treated at our institution. The database was queried to identify all patients who underwent CTS. Informed consent for participation in the study and the procedure was obtained from the patients by telephone. All patients underwent a functional study with measurement of levels of free triiodothyronine, free thyroxine, thyroid-stimulating hormone, thyroglobulin, antibodies against thyroperoxidase and thyroglobulin, and parathyroid hormone. Neck and chest computed tomography (CT) and magnetic resonance imaging for preoperative surgical planning were performed in all cases (Fig 1). Valsalva-Mueller tests confirmed tracheomalacia. Preoperative and postoperative bronchoscopy was performed to assess vocal cord function and the dynamic pattern of airway collapse and to evaluate postoperative status in these patients. The surgical procedures were performed by an experienced surgical team. The patients were intubated in the supine position, and they had either a limited vertical midline incision (1 of 7 patients) or a full median Accepted for publication Jan 27, 2015. Address correspondence to Dr Rusong, Department of Thoracic Surgery, Nanjing Chest Hospital, Guangzhou Rd 215, Nanjing, Jiangsu Province, 210029, China; e-mail: [email protected].
Ó 2015 by The Society of Thoracic Surgeons Published by Elsevier
0003-4975/$36.00 http://dx.doi.org/10.1016/j.athoracsur.2015.01.067
FEATURE ARTICLES
racheomalacia is a disorder of the large airways that is often caused by a large anterior mediastinal mass [1], which results in a spectrum of respiratory symptoms ranging from chronic cough to life-threatening apnea and airway obstruction. Several interventions described have limitations, and a definitive solution does not exist. This study describes 7 patients who underwent controlled trachea suspension (CTS) as a surgical intervention to prevent severe tracheomalacia and provide potent relief of airway symptoms in severe cases.
(Ann Thorac Surg 2015;99:2225–7) Ó 2015 by The Society of Thoracic Surgeons
2226
HOW TO DO IT LIU ET AL TRACHEA SUSPENSION FOR TRACHEOMALACIA
Fig 1. Chest computed tomography shows tracheal compression with narrowing of the lumen.
FEATURE ARTICLES
Results Seven patients (5 men and 2 women) with a median age of 54 years (range, 34 to 73 years) underwent CTS; this group comprised 4.5% (7 of 155) of all mediastinal tumors resected. The presentation for compressive symptoms was the reason for first access to medical care. All patients had tracheomalacia diagnosed by flexible bronchoscopy. Preoperative CT scans with three-dimensional airway reconstruction were performed to define the anatomic features and the severity of disease. The mean surgical time was 133.4 minutes (range, 76 to 218 minutes). Pathologic examination of gross specimens showed a mean weight of 891 g (range, 504 to 1830 g) with a mean diameter of 14.5 cm (range, 12.2 to 17.5 cm). Histologic examination demonstrated substernal mediastinal goiter in 3 patients, thymoma in 3 patients, and thymic carcinoma in 1 patient.
Ann Thorac Surg 2015;99:2225–7
Fig 3. The sutures are then sequentially passed through the sternal plate and twisted around a tension suture plate.
All patients were mechanically ventilated after the surgical procedure for 8 to 48 hours, and they were successfully extubated. No patient required continuous positive airway pressure or suffered acute lifethreatening events. Four patients developed dyspnea immediately to 3 hours after the suspension sutures were released, and they recovered after the dragging sutures were tightened. Additional attempts to release the sutures were made every second day. One patient underwent two attempts and recovered without suspension sutures, 2 patients underwent two attempts, and 1 patient underwent three attempts. No permanent recurrent laryngeal nerve palsy occurred. All patients survived and were discharged, with a median total length of stay of 25 days (range, 14 to 29 days) and a median postsurgical length of stay of 14 days (range, 10 to 16). Median follow-up time was 12 months (range, 5 to 36 months). These patients recovered without complications or other notable events, signs of tumor recurrence, or metastasis. Pulmonary function tests were performed 6 months after the surgical procedure; the mean ratio of forced expiratory volume in 1 second to forced vital capacity (FEV1/FVC) was 87.7% (range, 69.5% to 105.9%), and the mean maximum voluntary ventilation was 84.4 L/minute (range, 59.5 to 97.9 L/minute).
Comment
Fig 2. The 3-0 Prolene (Ethicon, Somerville, NJ) vertical sutures are placed through the anterior tracheal fascia through two cartilage rings.
Any cervical or mediastinal lesion compressing the trachea could lead to tracheomalacia by compromising the blood and nutrient flow to the supporting cartilage, with resulting postoperative softening and collapse of the trachea wall [2, 3]. Tracheomalacia should be intensively considered. The extent of underlying malacia secondary to chronic tracheal compression cannot be assessed until surgical removal of the extrinsic compression [4]. The compressive effects could be simulated by applying suction to the airway through the bronchoscope. Judgment regarding management must be made when a malacic segment is discovered. If the segment is completely devoid of structural cartilage and is severely malacic, tracheal suspension is indicated. Otherwise, mild to moderate
Ann Thorac Surg 2015;99:2225–7
malacia can be retained without attempting surgical correction. Endotracheal suspension, tracheotomy, and tracheal stents are possible surgical options. However, hemorrhage, wound infection, decannulation, tracheal stenosis, and other complications may be associated with these procedures, thus indicating that less traumatic manipulation should be considered [5, 6]. CTS provides specific support to the affected region and produces an impressive direct effect on the anterior cartilage. Caution must be taken to avoid distortion of the airway as a result of excessive tension on the sutures. Careful assessment must be made to ensure safe pathways for the suspension sutures. Sutures should not penetrate whole trachea layers, to avoid mediastinal infection or emphysema caused by air leakage. A retention bar could provide better support for sutures and cause less harm to the tissue around the sutures because of its high strength and low pressure on skin. Twisted to a retention bar, suspension sutures are tightly fastened, and they could be easily loosened. Several days after the surgical procedure, when the trachea adheres to the surrounding tissue, sutures could be loosened. If no signs of trachea collapse are observed, the sutures and bar could be removed; otherwise, sutures should be tightly fastened again if stridor or other symptoms
HOW TO DO IT LIU ET AL TRACHEA SUSPENSION FOR TRACHEOMALACIA
2227
related to trachea collapse occur until tracheal rings provide enough strength for breathing. Currently, we perform CTS in all patients with severe tracheomalacia who are candidates for tracheostomy or chronic ventilator support, and these patients are functioning well postsurgically. The findings of this report suggest that CTS may be safe and effective with little postoperative discomfort, and it should be considered to treat tracheomalacia after resection of a large anterior mediastinal mass.
References 1. Kugler C, Stanzel F. Tracheomalacia. Thorac Surg Clin 2014;24:51–8. 2. Vasko JS, Ahn C. Surgical management of secondary tracheomalacia. Ann Thorac Surg 1968;6:269–72. 3. Cogbill TH, Moore FA, Accurso FJ, Lilly JR. Primary tracheomalacia. Ann Thorac Surg 1983;35:538–41. 4. Cho JH, Kim HJ, Kim J. External tracheal stabilization technique for acquired tracheomalacia using a tailored silicone tube. Ann Thorac Surg 2012;94:1356–8. 5. Mitchell ME, Rumman R, Chun RH, et al. Anterior tracheal suspension for tracheobronchomalacia in infants and children. Ann Thorac Surg 2014;98:1246–53. 6. Carden KA, Boiselle PM, Waltz DA, Ernst A. Tracheomalacia and tracheobronchomalacia in children and adults: an indepth review. Chest 2005;127:984–1005.
FEATURE ARTICLES
