About tracheostomy for tracheal scar cicatricial stenosis

Background. Despite notable progress in tracheal surgery, the treatment of patients with tracheal scar stenosis continues to be considered highly specialized care and is limited to a fairly narrow range of medical institutions and a small number of relevant specialists. Not only thoracic surgeons, but also ENT specialists, endoscopists, general surgeons, and intensive care physicians provide emergency care. In this case, there are currently 3 possible surgical
options — tracheal resection with intertracheal or tracheo-laryngeal anastomosis, multistage operations with a long- term formation of the airway lumen on a T-tube, and a wide range of intraluminal tracheoscopy interventions. Special
mention should be made of emergency care for patients with scar stenosis of the trachea and decompensated respiration, with the threat of asphyxia. In these cases, the main goal is to restore safe breathing. Endoscopic recanalization of the trachea and/or larynx is considered the optimal solution. However, this invasive intervention requires technical support and, most importantly, the availability of an experienced specialist. There are major problems with this in our country. Therefore, in the routine practice, emergency care is usually limited to tracheostomy, which may then significantly limit the possibility of definitive radical treatment of the patient or increase the risk associated with these interventions. The situation becomes even more problematic considering that these patients are often treated in non-specialized medical facilities with little experience in tracheal
surgery. Tracheostomy itself in tracheal scar stenosis can be a technically challenging operation. Mini-invasive variants of percutaneous dilatational tracheostomy have not found their place tracheal scar stenosis and require
separate study and discussion. In this regard, the development of specific recommendations and the improvement of technical approaches to various modifications of tracheostomy seem to be relevant.

Material and methods. In total, about 1500 patients with tracheal scar stenosis were treated at the Petrovsky National Research Centre of Surgery, and then at the Sechenov University and FNMRC of Phthisiopulmonology and
Infectious Diseases of the Ministry of Health of the Russian Federation from 1963 to 2022. The present study included 1253 patients who underwent surgical treatment between 2004 and 2024. In most cases, the initial etiopathogenetic
factor was tracheal injury during resuscitative measures with ineffective independent breathing (86.7% of patients). In this case, scar stenosis occurred more often post-tracheostomy (44.7% of patients), less often – post-intubation (42%). As a result of previous surgical interventions, open or closed tracheal trauma, the stenosis occurred much less frequently. Idiopathic stenosis was diagnosed in 76 patients (6%) At the first visit, 61.6% of patients had a tracheostomy. It could be performed as a first aid in case of critical airway
narrowing, or it retained from the intensive care stage, when scar stenosis was diagnosed after the patient regained independent breathing and was disconnected from the ventilator in the intensive care unit.

Results. Most patients had previously undergone tracheostomy for various indications. Moreover, this operation could be performed several times (maximum 4). According to the presented documents, re-tracheostomy was performed
more often in case of tracheal restenosis. At the same time, another decannulation seems to be unjustified and testifies to insufficient training of doctors in this issue. Based on the retrospective analysis of the etiopathogenesis of the disease, technical peculiarities of tracheostomy, recommendations concerning the choice of tracheostomy option and peculiarities of re-tracheostomy in scar stenosis are proposed.

Conclusions. Tracheostomy should remain in the surgical armamentarium for patients with tracheal scar stenosis. At the same time, it can be a complex and sometimes risky operation requiring certain experience of the operating
surgeon. It should be performed when the patient’s breathing cannot be restored by endoscopic intraluminal methods for various reasons. Refusal of tracheostomy or intraluminal dilation because of the risk of possible complications and attempting to transport a patient with stridor to a specialized department cannot be considered an adequate tactic. Percutaneous dilatational tracheostomy is a modern, promising and minimally invasive technique. However, it is rarely used in scar stenosis. It can be performed when the stenosis is localized in the distal part of the trachea,
in the thoracic section, when it is possible to bougie the narrowed segment via neck access. Tracheostomy is also used in the management of complications after reconstructive tracheal surgery.
Key words: tracheostomy, scar stenosis of the trachea, complications of tracheostomy, tracheal surgery
Conflicts of interest. The authors have no conflicts of interest to declare.
Funding. There was no funding for this study