Transcript Chirurgiczne leczenie achalazji przełyku

PATHOLOGIES OF THE
TRACHEA
Department of Thoracic, General and Oncological Surgery
Medical University of Lodz
Head of the Department: Prof. Marian Brocki
Author of the lecture: Edyta Santorek-Strumiłło, MD
ETIOLOGY OF TRACHEAL STRICTURES
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prolonged endotracheal intubation,
tracheostomy,
92 % of strictures
direct and indirect tracheal injuries,
aspiration of a foreign body into the tracheal lumen,
tracheal burns,
tracheal wall infections,
other (sarcoidosis, tuberculosis, histoplasmosis),
primary benign and malignant tracheal tumors,
malignant infiltration of the trachea.
Introduction:
• An increasing number of patients treated due to
respiratory failure by prolonged endotracheal
intubation, mechanical ventilation and
tracheostomy causes the increase of a number of
airway obturations.
• According to different authors the rate of
complications of tracheostomy ranges from 2 % to
21%.
• There is only a low percentage of tracheal
stenoses that are symptomatic and demand
surgical treatment.
ENDOTRACHEAL INTUBATION
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Endotracheal intubation is a minimally-invasive
procedure. A plastic tube is introduced through the
month or nostrils into the tracheal lumen usually
under a laryngoscope control and is fixed within
the trachea by the inflation of a special balloon.
 It is a routine medical procedure used, among
others, during general anesthesia or resuscitation.
COMPLICATIONS OF ENDOTRACHEAL
INTUBATION
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injuries of the lips, teeth, tongue, tonsils, throat, larynx,
injury of the vocal cords,
injury of the trachea
laryngeal edema or spasm after intubation tube removal,
acute pulmonary distention or tension pneumothorax
infection of the airway,
errosions of the tracheal wall caused by an endotracheal tube
cuff pressure and chronic ischemia
A Fome-Cuf endotracheal tube
TRACHEOSTOMY
Tracheostomy is one of the most frequent procedure performed in
intensive care units, laryngologic and surgical departments as it
preserves the patency of the airway and enables effective
mechanical ventilation in patients with respiratory failure.
INDICATIONS FOR TRACHEOSTOMY :
 obstruction of the airway
 control of the secretions
 mechanical ventilatory support in respiratory failure
 decrease of dead respiratory space and the treatment for sleep apnea
TRACHEOSTOMY
 in patients that require mechanical ventilation for longer than
14 days tracheostomy should be performed as soon as
possible when their general state is stable enough.
 duration of endotracheal intubation shouldn’t be longer than
7 days and if extubation is not possible within next 5-7 days
due to patient’s general state tracheostomy must be done.
Relative anatomy
TYPES OF TRACHEOSTOMY TUBES
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CUFLESS TUBES
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CUFFED TUBES
TECHNIQUE
A. 3-cm long horizontal skin
incision is made 2 cm over the
sternal notch . Subhyoid
muscles are separated
vertically and the pretracheal
fascia is exposed. The thyroid
isthmus can be divided if it
hinders tracheal exposure.
TECHNIQUE
B. Tracheostomy is usually
done below the second
tracheal ring. The third
ring is elevated with a
sharp hook and a disk is
excised using a surgical
blade No 11.
TECHNIQUE
C. Any secretion is removed from
the airway and a tracheostomy tube
is introduced with its low-pressure
cuff collapsed. When the
tracheostomy tube is already
inserted its guiding mandril is
removed, surgical wound is sutured
and the tube is fastened
with tapes around the neck.
TECHNIQUE
D. In the case of initracheostomy
or if tracheostomy is performed
due to emergency conditions it is
done through the cricothyroid
membrane. A small skin incision is
made over the membrane and it
punctured with a mandril of
smaller diameter. The procedure is
carried out under local anesthesia.
TRACHEOSTOMY
COMPLICATIONS OF TRACHEOSTOMY –6%
EARLY COMPLICATIONS :
LATE COMPLICATIONS :
 hemorrhage
 tracheoarterial fistula
 abscess in tissues
 tracheoesophageal fistula
sourrounding a stomy
 subcutaneous emphysema
 postintubation tracheal
stricture
 mediastinal emphysema
 tracheomalacia
 dislocation of a tracheostomy
 persistent tracheocutaneous
tube
 tracheostomy tube obstruction
fistula
MAIN FACTORS RESPONSIBLE FOR POSTINTUBATION AND POST-TRACHEOSTOMY
TRACHEAL STENOSES :
 compression of an endotracheal tube to tracheal
mucosa
 movements of an endotracheal tube along the
tracheal wall
 bad surgical technique and improper care of
tracheostomy
 prolonged intubation
 pressure within a cuff over 30 mmHg
 infections
 patient’s general state (hypotension, hypoxia).
Tracheal stenosis after long-term
endotracheal intubation or tracheostomy
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Incidence: ~31%
 Site: Cuff level or stoma level
 Degree of stenosis:
11~25% in 18% patients,
26~50% in 22% patients,
>50% in 3.7% patients
only 3~20% were symptomatic (stenosis>30%)
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Symptoms: shortness of breath, inspiratory stridor,
expiratory wheeze
Tracheal stenosis after long-term
endotracheal intubation or tracheostomy diagnosis
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chest an neck roentgenograms
rigid/flexible bronchoscopy
computed tomography
spiral computed tomography
magnetic resonance imaging
spirometry
laryngoscopy,
fluoroscopy,
virtual bronchoscopy on the basis of computed picture
analysis
EBUS – endobronchial ultrasound.
CLASSIFICATION OF TRACHEAL STENOSES :
Classical classification :
 glottic stenosis
 subglottic stenosis
 stenosis of the cervical part of
the trachea
 stenosis of the mediastinal part
of the trachea
McCaffrey’s classification
I – subglottic stenosis shorter than 1 cm
II – isolated subglottic stenosis longer than
1 cm
III – subglottic stenosis without glottis
inclusion
IV – stenosis including the glottis
Cotton’s classification - based on the grade
of the tracheal lumen stenosis
I - stenosis < 70%
II - 70% < stenosis< 90%
III - stenosis > 90%
IV - complete obstruction of the trachea
Tracheal stenosis
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Web-like subglottic stricture
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Circumferential subglottic stenosis
TREATMENT OF TRACHEAL
STENOSES
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endoscopic dilation of a stricture (mechanical dilators, balloon
dilation) completed by laser therapy or argon plasma coagulation.
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mechanical ablation of granulation through a rigid bronchscope
( forceps, electroresection)
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endoscopic laser patency restoration (evaporation : CO2 -laser,
Nd:YAG laser),
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T-tube implantation,
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silicone stents
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expandable metallic stents
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tracheal resection with end-to-end anastomosis.
Indications for treatment :
Endocopic dilation : method of temporary tracheal lumen restoration
before final treatment. Used often due to emergency indications.
Drawbacks : risk of tracheal perforation, hemorrhage, short-term therapeutic
effect.
Laser therapy : effective ablation of granulation, membranous strictures
and central stenoses shorter than 4 cm with preserved partial lumen patency.
Enables dilation of the stricture and airway splinting. The method is ineffective
in a case of complete tracheal obstruction.
Drawbacks : risk of tracheal perforation, intensification of stenosis, arrythmia,
air embolism, risk of ignition of a fiberoptic bronchoscope and an intubation tube.
Indications for treatment :
Argon plasma coagulation : enables relatively safe repeatable
ablation of granulation during endoscopy (the depth of coagulation is
0.5-3 mm)
In some cases it gives permanent restoration of the tracheal lumen in
other cases it makes it possible to prepare a patient to a radical
treatment (resection, stent implantation)
Drawbacks : method ineffective in complete tracheal obstruction and
strictures longer than 1 cm.
Indications for treatment :
Stent implantation : high efficient, simple technique offering instant
improvement of respiratory function. It is usually used in patients in whom
surgery is contraindicated or a temporary protection of the tracheal lumen
patency is necessary before surgical treatment.
Drawbacks: granulation formation, retention of secretion, hemorrhage,
stent migration to the lower part of the trachea, stent rupture,
intolerance of stent, stent erosion into adjacent organs.
Tracheal resection
INDICATIONS :
Tracheal resection is presumed to be the most effective method for the
treatment of tracheal stenoses as it enables the elimination of the stricture
and restoration of a physiologic airway state.
The method gives good results in patients with benign isolated tracheal
stenoses not longer than 4 cm- maximally 6 cm and low surgical risk.
CONTRAINDICATIONS :
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stenosis > 50% of the tracheal length
multilevel stenosis
high stenosis (glottic or subglottic)
recurrence of stenosis after tracheal resection
bad patient’s general state
TRACHEAL RESECTION
Complications :
Early :
 laryngeal and tracheal
mucosa edema
 pneumothorax
 mediastinitis
 disturbances of phonation,
 dysphagia,
 hemorrhage,
 surgical wound infection
Late :
 formation of granuloma in
the line of anastomosis,
 recurrence of stenosis,
 retension of secretion in
the bronchial tree,
 tracheoesophageal fistula,
 tracheoarterial fistula.
NEOPLASTIC STENOSES OF THE
TRACHEA
Etiology of neoplastic tracheal stenosis :
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adenomas,
carcinomas (primary tracheal carcinomas are extremely rare)
papillomas,
polyps,
lipomas,
chondromas,
malignant tumors of adjacent tissues infiltrating the trachea
(esophageal tumors, thyroid tumors, mediastinal tumors )
NEOPLASTIC STENOSES OF THE
TRACHEA
Symptoms and signs of neoplastic tracheal stenoses are similar to
those observed in postintubation strictures. A basic sign is an
increasing dyspnea.
Hemoptysis and retrosternal pains are observed more frequently in
neoplastic than in postintubation stenoses.
DIAGNOSIS OF TRACHEAL TUMORS:
 laryngoscopy
 tracheal endoscopy and endoscopic biopsy
 x-ray examination
 computed tomography
 magnetic resonance imaging
NEOPLASTIC STENOSES OF THE
TRACHEA
TREATMENT:
 endoscopic resection of benign tumors
 endoscopic resection of a benign tumor + ablation of residual tumor tissues with
argon plasma coagulation
 partial tracheal resection for benign and selected malignant tumors (subglottic
tumors, tumors invading adjacent tissues and tumors involving more than 4 cm
of the tracheal length are unsuitable for resection as oncological margins can’t
be achieved)
 palliative methods for the restoration of the tracheal lumen in inoperable tumors
(laser, argon plasma coagulation, expandable stents, T-tube)
 resection of larger than 6 cm of the trachea with the implantation of a prosthesis
RECAPITULATION :
The resection of the cervical part of the trachea for
postintubation stenosis is a safe procedure if a patient is
qualified properly for this method of treatment. It means
that his or her general state, the localization and length of
the stenosis meet the conditions for resection.
To perform the procedure successfully, apart from its
technical aspects, an experienced anesthesiologist having
necessary equipment to provide effective patient
ventilation during the operation and good postoperative
care is an indispensable condition.