Management of Tracheal Surgery Complications Gunda Leschber INTRODUCTION Tracheal surgery in general is only rarely compli- cated by undesired effects; however, if complica- tions occur, they can lead to severe morbidity. 1–3 Several factors influence the outcome after tra- cheal surgery, such as reoperations, preoperative tracheostomy, diabetes, pediatric patients, or the length of the resected segment. 1 Prevention of complications starts preopera- tively with treatment of acute infectious or inflam- matory conditions. 4 A noninflamed mucosa is optimal for surgery and there is seldom a need for rushing an operative procedure. 2 Intraoperative complications are extremely infrequent if the operative team is familiar with airway surgery (ie, surgeon, anesthetist, and as- sisting personnel), because there is a learning curve. 3,5 Management of intubation (via bronchos- copy or over the operative field) and handling of extended resections with release maneuvers do not pose a problem for an experienced team. Some postoperative complications however origi- nate from intraoperative manipulation. These com- plications are anastomotic granulations, stenosis, or anastomotic dehiscence as well as bleeding from vessel arrosion. Other complications include injuries of recurrent laryngeal nerve, arrhythmias, pneumonia, or wound infection. PREVALENCE OF POSTOPERATIVE COMPLICATIONS IN TRACHEAL SURGERY The most complete analysis of anastomotic com- plications after tracheal operation was presented in 2004 by Wright and colleagues 1 from the Massa- chusetts General Hospital (MGH). In their review of 901 patients they identified relevant risk factors and described the management of problems. Anastomotic complications included granulations at the suture line, stenosis, and tracheal separa- tion. A good result at the end of treatment was Disclosure: None. Department of Thoracic Surgery, ELK Berlin Chest Hospital, Lindenberger Weg 27, Berlin 13125, Germany E-mail address: [email protected]KEYWORDS Tracheal surgery complications Granuloma Dehiscence Restenosis Tracheo-innominate artery fistula KEY POINTS There are several factors influencing the success of tracheal operations and the rate of complications. Besides risk factors on the part of the patient, such as prior tracheal surgery, tracheostomy tube in place, extent and localization of the tracheal disease, and need for release maneuvers, the experi- ence of the surgeon also plays a major role in preventing complications. Good clinical judgment, careful planning of the procedure, and meticulous dissection as well as knowledge of salvage maneuvers will result in a low complication rate in tracheal surgery. The learning curve of tracheal surgery includes intraoperative experience and dealing with postop- erative complications. Often observing further healing (“wait and see”) instead of premature action will result in good outcome. Thorac Surg Clin 24 (2014) 107–116 http://dx.doi.org/10.1016/j.thorsurg.2013.09.002 1547-4127/14/$ – see front matter Ó 2014 Elsevier Inc. All rights reserved. thoracic.theclinics.com
� There are several factors influencing the success of tracheal operations and the rate ofcomplications.
� Besides risk factors on the part of the patient, such as prior tracheal surgery, tracheostomy tube inplace, extent and localization of the tracheal disease, and need for release maneuvers, the experi-ence of the surgeon also plays a major role in preventing complications.
� Good clinical judgment, careful planning of the procedure, and meticulous dissection as well asknowledge of salvage maneuvers will result in a low complication rate in tracheal surgery.
� The learning curve of tracheal surgery includes intraoperative experience and dealing with postop-erative complications.
� Often observing further healing (“wait and see”) instead of premature action will result in goodoutcome.
m
INTRODUCTION
Tracheal surgery in general is only rarely compli-cated by undesired effects; however, if complica-tions occur, they can lead to severe morbidity.1–3
Several factors influence the outcome after tra-cheal surgery, such as reoperations, preoperativetracheostomy, diabetes, pediatric patients, or thelength of the resected segment.1
Prevention of complications starts preopera-tively with treatment of acute infectious or inflam-matory conditions.4 A noninflamed mucosa isoptimal for surgery and there is seldom a needfor rushing an operative procedure.2
Intraoperative complications are extremelyinfrequent if the operative team is familiar withairway surgery (ie, surgeon, anesthetist, and as-sisting personnel), because there is a learningcurve.3,5 Management of intubation (via bronchos-copy or over the operative field) and handling ofextended resections with release maneuvers do
Disclosure: None.Department of Thoracic Surgery, ELK Berlin Chest HospitE-mail address: [email protected]
Thorac Surg Clin 24 (2014) 107–116http://dx.doi.org/10.1016/j.thorsurg.2013.09.0021547-4127/14/$ – see front matter � 2014 Elsevier Inc. All
not pose a problem for an experienced team.Some postoperative complications however origi-nate from intraoperative manipulation. These com-plications are anastomotic granulations, stenosis,or anastomotic dehiscence as well as bleedingfrom vessel arrosion. Other complications includeinjuries of recurrent laryngeal nerve, arrhythmias,pneumonia, or wound infection.
PREVALENCE OF POSTOPERATIVECOMPLICATIONS IN TRACHEAL SURGERY
The most complete analysis of anastomotic com-plications after tracheal operation was presentedin 2004 byWright and colleagues1 from theMassa-chusetts General Hospital (MGH). In their review of901 patients they identified relevant risk factorsand described the management of problems.Anastomotic complications included granulationsat the suture line, stenosis, and tracheal separa-tion. A good result at the end of treatment was
seen in 95% of patients with no need for a trache-ostomy tube or T-tube (Table 1). Four percent ofpatients needed a permanent airway appliance,andmortality was 1.2%. They analyzed different in-dications of airway surgery and their complicationrate (postintubation stenosis, tracheoesophagealfistula, laryngotracheal stenosis, and tumor). Over-all complications were observedmost frequently inthe tracheoesophageal fistula group (28.6%) withanastomotic complications in 14.3% because thisis the most complex group with often a tracheos-tomy in place (which is considered an independentrisk factor because it renders the operative field in-fectious). The fewest problems with the anasto-mosis (2.4%) were seen in the laryngotrachealstenosis group for a total complication rate of6.6% in this group. Eighty-one patients (9%) expe-rienced anastomotic complications in their series:37 patients had dehiscence, 7 had granulationwith airway obstruction, and 37 developed steno-sis. Treatment included multiple dilations (n 5 2),temporary tracheostomy (n 5 7), tracheal T-tube(n 5 16), permanent tracheostomy (n 5 14), orT-tube (n 5 20) as well as reoperation (n 5 16). Ifanastomotic complications occurred, mortalitywas 7.4% (6/81) compared with 0.06% (5/820) inthose without anastomotic problems. Since 1988no patients died, which is attributed to the routineuse of postoperative bronchoscopy for earlyrecognition a problems. They also described a sig-nificant reduction in suture granuloma formationsince the conversion to absorbable suturematerial.Wright and colleagues identified several predic-
tors of anastomotic complications: reoperation,preoperative tracheostomy, lengthy (>4 cm) resec-tions, and the need for a release maneuver. Other
Table 1Anastomotic complications after trachealresection: results of MGH
Adapted from Wright CD, Grillo HC, Wain JC, et al.Anastomotic complications after tracheal resection: prog-nostic factors and management. J Thorac Cardiovasc Surg2004;128(5):733; with permission.
predictors of anastomotic complications were dia-betes, age less than 17 years, and laryngotrachealresections (Table 2). The release maneuver itselfwas not considered an independent risk factorbecause it only indicated the need for extensiveresection. Neither obesity nor corticosteroid usewas associated with an increased complicationrate. Management strategy is to postpone trachealoperations in the presence of high-dose steroidsuntil they are effectively tapered.D’Andrilli and coworkers6 summarized compli-
cations frommultiple studies in laryngotracheal re-sections for benign stenosis (Table 3). Again,success rates were greater than 91%. In theirown group over a period of 16 years (with amean follow-up of 61 months) they observed arestenosis rate of 11.4%. These patients were suc-cessfully treated by endoscopic interventions withfinal success of 100%. Friedel and coworkers7
evaluated the long-term results of 110 trachealsegmental resections performed between 1985and 2001. Again, healing of the anastomosis wasuncomplicated in 91.8% (101 patients) andcomplication rates were according to what isdescribed in the literature. They interviewed 77 pa-tients for the long-term results 12 to 226 monthspostoperatively (median 80.1 months): 93.5%(n 5 72) were satisfied with the surgical treatment,75.3% were without discomfort, 9.1% reportedstridor when exercising, and 11.7% complainedof occasional hoarseness. Three patients requiredreoperation for restenosis because of suturedehiscence, foreign body granuloma, and local-ized recurrence of mucoepidermoid carcinoma.Only 6.5% (5 patients) were not satisfied with theresults of surgery because of persistent hoarse-ness and stridor under exercise.
PREVENTION OF COMPLICATIONS INTRACHEAL SURGERY
To achieve low complication rates in tracheal sur-gery, it is important to have a concept of protectivestrategy before operating.
Exact Planning of Operative Procedure
Before operation, the cause and location of thetracheal disease should be fully understood, sothe surgeon can exactly plan the operative proce-dure and thereby reduce probable complications.Tracheal surgery, more than other operations,warrants an interdisciplinary approach whereby itis important to have competent partners, not onlyanesthetists but also otolaryngologists and bron-choscopists, if necessary. Besides the “how-to-do-it” also the timing of the operation or necessary
Table 2Predictors of anastomotic complications resection: results of MGH
Adapted fromWright CD, Grillo HC, Wain JC, et al. Anastomotic complications after tracheal resection: prognostic factorsand management. J Thorac Cardiovasc Surg 2004;128(5):733; with permission.
Management of Tracheal Surgery Complications 109
preoperative preparations are best discussedtogether to achieve optimal results.
Knowledge of Patient’s History
It is important to be familiar with the history of thedisease, prior surgical attempts, or the placementof a tracheostomy tube. Corticosteroids should beterminated or tapered as much as possible beforesurgery because they are responsible for adversewound-healing effects.
Knowledge of Radiological Findings
A posteroanterior chest radiograph may revealsome tracheal pathologic abnormality. However,the standard now is high-resolution computed
Table 3Complications in laryngotracheal resections in benig
Author (year) Pts
Results
Re(%
Successes(%)
Failures(%)
Grillo, 1995 62 92 8 5.
Couraud,1995
57 98.2 1.8 0
Macchiarini,2001
45 96 4 4.
Ashiku, 2004 73 91 9 8.
D’Andrilli,2008
35 Early: 85.7Definitive: 100
Early: 14.3Definitive: 0
11
a Restenoses 1 dehiscences.Data from D’Andrilli A, Rendina EA, Venuta F. Tracheal surg
tomographic (CT) scan with 3-dimensional re-construction. It allows determination of the extra-luminal component of underlying pathologicabnormality in the case of malignant disease orthe longitudinal extension of the stenosis (Fig. 1).
Bronchoscopy by the Surgeon
Bronchoscopy is the key element to confirm thediagnosis and plan the operative strategy. Eithera rigid or a flexible scope can be used to measurethe length of stenosis as well as the length ofnormal trachea available, both proximal and distalto the pathologic abnormality. It can also identifythe anatomic relations, cricoid, and first trachealring (Fig. 2).
n stenosis
stenosis)
Compl.(%)
Mortality(%)
Reop(%)
Dehiscence(%)
5a 33 2.4 3.4 5.5a
3.5 1.8 0 1.8
4 41 2 2.2 0
3 8.2 0 0 0
.4 11.3 0 0 2.9
ery. Monaldi Arch Chest Dis 2010;73(3):108.
Fig. 1. (A, B) CT scan of a tumor with calcifications (black arrow), located behind the trachea.
Leschber110
Treatment of Mucosal Inflammation orTracheobronchial Infection
In the case of mucosal inflammation or ulcerations,surgery should be delayed until mucosal healingoccurs. If this is due to a tracheostomy tube, itmay require a change to a smaller tube or ifpossibly even a short period of decannulation. Inpatients with idiopathic laryngotracheal stenosiswith active inflammation an attempt of dilatationis indicated until the inflammatory state of theairway mucosa subsides. Tracheobronchial infec-tions should be treated preoperatively accordingto the microbiologic evaluation to achieve optimalcondition for surgery.
Intraoperative Measures for Prevention ofComplications
Intraoperatively handling of the trachea should beas gentle as possible, which can be difficult intense adhesions and scar tissue from previous
Fig. 2. Preoperative bronchoscopy: anatomic relationof a localized stenosis in the upper trachea: note thevocal cords (black arrows) and cricoid (white arrow-head). The mucosa shows signs of inflammation.
operations. Staying close to the tracheal wallavoids impairment of the recurrent laryngeal nerveor laceration of the esophagus. The use of pinpointbipolar coagulation in the vicinity of trachea andnerve also prevents damage. Denudation fromthe adjacent tissue must be avoided to keep bloodsupply intact. If the trachea at the distal end of thestenosis is incised transversally, the ventral part ofthe stenosis can be opened, allowing resection ofthe stenosis under direct vision and freeing of theposterior wall as well.Approximation of the cut ends for the anasto-
mosis is facilitated by stay sutures in the cranialand caudal parts, which are held by the assistant;also flexion of the neck when the sutures are tieddecreased tension at the suture line. Extubationat the end of the operative procedure is good pro-tection from further disturbances of mucosal bloodflow and should be done whenever possible.
Postoperative Care
Goodaftercare is essential to patientswhohaveun-dergone tracheal operations because respiratorydifficulties may require immediate intervention. Pa-tients should be observed in the intensive care unitfor signs of swelling of the anastomosis or bleedingand for phonation and swallowing. If immediate ex-tubation was not possible, weaning from mechani-cal ventilation should be attempted as soon aspossible.Patients should have their neck in anteflexion
with a pillow all the times for at least 5 days andavoid brisk movements of the head. In the author’sexperience, it is not necessary to use any chin-to-chest-stitches.
COMPLICATION MANAGEMENT DURING THETRACHEAL RESECTIONProblems with Ventilation
At induction of anesthesia problems may occur.An experienced anesthetist and the surgeon
Management of Tracheal Surgery Complications 111
should be available as well as (rigid) broncho-scopes of different sizes. Bronchoscopic dilatationbefore intubation allows insertion of an endotra-cheal tube larger than expected from the stenosis.In fixed stenosis, impossible to be dilated, only asmall endotracheal tube can be placed distally tothe obstructive lesion. In the rare event that venti-lation cannot be installed, an emergency trans-verse incision of the trachea and intubation overthe operative field will save the patient’s life. Intra-operatively a cross-field intubation may becomenecessary if jet ventilation fails to achieve sufficientoxygenation or elimination of CO2.
Tension of Anastomosis
While completing the tracheal anastomosis, ten-sion should be kept to a minimum. Until now theonly way to judge anastomotic tension is experi-ence because no viable method exists to deter-mine constant tension. A short residual tracheaincreases the tension of the anastomosis. If thisis only minor, a long additional stay suture be-tween tracheal rings above and below the anasto-mosis on the anterior part of the trachea can beplaced to reduce anastomotic tension. However,surgeons performing tracheal surgery must befamiliar with release maneuvers, which are indi-cated in cases with short residual trachea (ie,mobilization of the larynx, the main bronchi, orpericardial incision; see Hecker and colleagues inthis issue). Flexing the neck anteriorly lowers thetension while performing the anastomosis. Post-operatively the patient needs to keep the neckflexed for at least a week. One simple methoddescribed in the literature is to sew the lower jawto the anterior chest wall with a suture. However,in the author’s experience as well as others,7 anextra pillow is sufficient to assure anteflexion incooperative patients.
Bleeding
During resection of the diseased segment of thetrachea, meticulous hemostasis is indicated.Bleeding from the peritracheal tissue or the mu-cosa can cause annoyance during formation ofthe anastomosis. The use of bipolar forceps isvery helpful to stop bleeding from the mucosabecause of its efficiency and limitation of damage,especially close to the recurrent laryngeal nerve.
Resection of Wrong Trachea Level
Reference to preoperative bronchoscopy (level ofthe diseased part in relation to cricoid or the bifur-cation) and CT will enable the experienced sur-geon to define the exact level of resection.Intraoperatively thyroid, cricoid, and carina are
anatomic landmarks for positioning but extensivescar tissue may obscure orientation in somecases. Then, intraoperative bronchoscopy forlocalization of the lesion should be performed bythe anesthetist while the surgeon inserts a needlethrough the tracheal wall to define the level of dis-ease. Exploring the extent of the stenosis underdirect vision can be performed if the ventraltracheal wall is opened.
These tricks should avoid resection of the wrongtrachea height. If, however, a false level is resected,further mobilization of the trachea (ie, with releasemaneuvers) is indicated.
Level of Stenosis is Higher than Expected
If intraoperatively found that the level of stenosisextends higher than preoperatively expected, acricotracheal resection may be indicated. It maybe sufficient to perform a Pearson procedure,8 oran additional Montgomery suprahyoid release ofthe larynx may be necessary to gain an additional1.5 cm of length9; these are release maneuverseffective for achieving additional mobility of thecervical trachea.
MANAGEMENT OF POSTOPERATIVECOMPLICATIONSBleeding Caused by Tracheo-innominateArtery Fistula
Bleeding within the first 2 days postoperatively ismore likely due to venous injury of the inferior thy-roid or the anterior jugular veins. In contrast, for-mation of a tracheo-innominate artery fistula is arare complication (0.1%–1%).10 An ongoing infec-tion at the site of the anastomosis or a tracheos-tomy tube is cause for the formation of a such afistula, which explains why this occurs generallywithin the first 3 weeks postoperatively (72% ofcases).11
In about 50% a herald bleed precedes themassive hemorrhage so, if de novo minor bleedingfrom the tracheal tube or the surrounding struc-tures is observed, immediate investigation shouldbe initiated. One should be prepared to maintainthe airway with an endotracheal tube and havesuction available to remove blood from theoropharynx or trachea if a sentinel bleed is sus-pected. A bronchoscopy (flexible and/or rigid)should be performed in the operating room withcareful removal of the tracheostomy tube. Becauseof the anatomic relation, the injury most likelyoccurs at the level of the seventh to nineth trachealring but with the variability of the innominate artery(brachiocephalic artery) it can occur also at higherlevels of the trachea.
Leschber112
If a massive hemorrhage occurs from the tra-chea, the initial goal is to control the airway byendotracheal intubation. At the same time anattempt to tamponade the bleeding should beundertaken while the patient is resuscitated andprepared for surgery. Compression of thetracheo-innominate artery fistula by overinflatingthe tracheal cuff as a first maneuver can be suc-cessful.12 If not, blunt finger dissection of the pre-tracheal space should be performed down to thelevel of the innominate artery after widening thetracheostomy incision. The innominate artery canthen be pressed against the posterior sternum tocontrol the bleeding (Fig. 3).When the diagnosis of tracheo-innominate ar-
tery fistula is clear on presentation, the patientshould be intubated immediately with the endotra-cheal tube inserted distally and the balloon inflatedfor prevention of bleeding into the distal airway forexpeditious transportation to the operating room.Manual compression of the fistula should beattempted.
Operative Management
Median sternotomy provides the best exposureand is expedient. However, it can result in postop-erative mediastinitis because of the infectiousorigin of the tracheo-innominate artery fistula(studies describe up to 40%).10 As soon as the
innominate artery (brachiocephalic artery) is identi-fied, it is clamped proximally and distally (Fig. 4). (Itmay be necessary to mobilize and divide theinnominate vein first.) The involved part is resectedand the healthy proximal and distal ends of theinnominate artery are stapled, oversewn, or ligated(Fig. 5).13 The incidence of stroke is low after sucha maneuver but care should be taken to ligate theartery proximally to the bifurcation of the right sub-clavian and common carotid arteries. Because ofthe division of the innominate artery one shouldhave a left radial arterial line in place for bloodpressure monitoring and a large-bore venous ac-cess in the femoral or right subclavian veinsbecause of possible innominate vein ligation.There is a controversy about immediate recon-
struction of the innominate artery because of thehigh risk of recurrent bleeding (60%–86%).11 How-ever, in the presence of severe left carotid arterystenosis/occlusion or a patent right internal mam-mary artery bypass graft, this could be considered.The interposition is done by a vein graft (saphe-nous or jugular vein). It is not recommended toperform a segmental resection and primary repairof the artery (without interposition) because ten-sion seems to be too high with a risk of recurrentbleeding.Sorial and coworkers14 in 2007 described suc-
cessful percutaneous stent graft insertion for con-trol of an acute hemorrhage in infected operative
Fig. 3. Digital compression of innom-inate artery against the sternum. a.,artery. (From Ailawadi G. Techniquefor managing tracheo-innominate ar-tery fistula. Oper Tech Thorac Cardio-vasc Surg 2009;14:68. Copyright 2009;with permission.)
Fig. 4. Clamping of innominateartery proximal and distal to the fis-tula. a., artery; v., vein. (From Aila-wadi G. Technique for managingtracheoinnominate artery fistula.Oper Tech Thorac Cardiovasc Surg2009;14:69. Copyright 2009; withpermission.)
Management of Tracheal Surgery Complications 113
fields as a bridging procedure. Depending on thestatus of the patient, debridement and reconstruc-tion of the innominate artery can be performed at alater date.
Following separation of the artery, the tracheallesion is debrided up to the healthy part and thenrepaired with interrupted sutures. For additionalsecuring of the tracheal wound or separation of
Fig. 5. Suturing of innominate arteryand trachea. a., artery. (From Aila-wadi G. Technique for managingtracheo-innominate artery fistula.Oper Tech Thorac Cardiovasc Surg2009;14:70. Copyright 2009; withpermission.)
Leschber114
trachea and innominate artery, a muscle flap usingthe sternocleidomastoideus or strap muscles isbuttressed to the trachea (Fig. 6). Sashida andArashiro15 described an anatomic reconstructionby a synthetic graft in combination with a pectora-lis muscle flap.
Granuloma Formation at the Anastomotic Site
A certain degree of intraluminal granulation at theanastomotic site is seen frequently after trachealsurgery in the postoperative phase without anyneed for intervention. It should be controlled bybronchoscopy because in most cases it willresolve spontaneously. It is important to refrainfrom unnecessary interventions! Patience on thepart of the surgeon is often the key to success(Fig. 7).However, if a more distinct granuloma forms at
the anastomosis, bronchoscopy should rule outthat this is due to loose sutures. Sometimes suturematerial creates a permanent irritation at the levelof the mucosa and by removing these suturesgranuloma will resolve by itself. The use of absorb-able sutures has decreased the incidence of gran-uloma formation.1,7 Another presumed reason is
some degree of separation of the anastomosis, al-lowing ingrowth of granulation tissue.1
An alternative of removal of persistent granu-loma is laser ablation through the bronchoscope.Various types of laser are used routinely in medi-cine and, depending of the depth of the coagula-tion, the laser type should be chosen.16 TheNd:YAG laser is widely used for this indication asthe maximum depth of penetration is approxi-mately 4 mm. The surgeon or bronchoscopist per-forming the laser ablation must be familiar with theanatomy and the laser to remove the granulomawithout doing further harm to the anastomosis ormucosa.
Dehiscence of the Anastomosis
Anastomotic dehiscence, a more severe compli-cation, can occur in different degrees. It presentseither as partial separation, mainly of the cartilag-inous part of the anastomosis, or as complete sep-aration with total dehiscence, which is a dramaticevent. In minor degrees one would just observe ifhealing occurs spontaneously, which is often thecase.7 It may be necessary to open the cervicalwound to drain a peritracheal abscess, which
Fig. 6. Buttressingof themuscle to thetrachea. (From Ailawadi G. Techniquefor managing tracheo-innominateartery fistula. Oper Tech Thorac Cardi-ovasc Surg 2009;14:66–72. Copyright2009; with permission.)
Fig. 7. (A–C) Resolution of granuloma at the anastomotic site following resection of a tracheal stenosis (samepatient as in Fig. 2). (A) 10 d postoperatively. (B) 1 month postoperatively. (C) 3 months postoperatively.
Management of Tracheal Surgery Complications 115
caused the partial dehiscence.2 Repeat bronchos-copy is performed to assess if a more severedehiscence develops. Then, insertion of a t-tubeis indicated; in rare cases an attempt to reoperatecan be made. Placement of stent can be dis-cussed but because of the already impaired bloodsupply of the tracheal wall additional pressure by astent may further deteriorate the healing process.
Restenosis
If restenosis occurs, management will be the sameas for primary stenosis (ie, evaluation for reopera-tion, laser therapy, and stent or tracheostomyplacement). Depending on the time point of devel-opment of a restenosis, themethod should be cho-sen. An early restenosis is an indication forinsufficient resection of the primary disease andmay be cured by reoperation by a more experi-enced tracheal surgeon.However,most restenosesdevelop over a longer period of time. Both granula-tions and dehiscence can lead to an anastomoticstenosis, which can also be caused by insufficientperfusion of the tracheal wall. Patients should beinformed about the risks of redo procedures.
CONCLUSION
In conclusion, there are several factors influencingthe success of tracheal operations and the rate ofcomplications. Besides risk factors from the pa-tient, such as prior tracheal surgery, tracheostomytube in place, extent and localization of thetracheal disease, and need for release maneuvers,the experience of the surgeon also plays a majorrole in preventing complications. Good clinicaljudgment, careful planning of the procedure, andmeticulous dissection as well as knowledge ofsalvage maneuvers results in a low complicationrates in tracheal surgery. The learning curve oftracheal surgery has been described by many au-thors3,5: this includes intraoperative experienceand dealing with postoperative complications.Often observing further healing (“wait and see”)instead of premature action will result in a goodoutcome.
REFERENCES
1. Wright CD, Grillo HC, Wain JC, et al. Anastomotic
complications after tracheal resection: prognostic
