A Novel Hybrid Procedure Combining Resection and Tracheoplasty for Complex Laryngotracheal Stenosis

Adult airway stenosis is a common condition treated in the otolaryngology clinic. Patients with high-grade, long-segment stenosis often fail endoscopic management. We describe the successful use of a hybrid resection and laryngotracheoplasty procedure that maximizes airway luminal patency in adults with successful decannulation. Laryngoscope, 2024 Open surgical treatments for laryngotracheal stenosis in adults commonly include primary resection with anastomosis, such as cricotracheal resection (CTR)/tracheal resection (TR) or staged laryngotracheoplasty (LTP).1 The indications, techniques, advantages, and disadvantages for these two approaches differ. Airway resection with primary anastomosis is optimal for shorter-segment (<3 cm) high-grade (Grade 3–4) stenosis and has maximum potential for creating normal luminal diameter. Additional benefits include single-stage procedure not requiring stent placement. However, a tension-free anastomosis is challenging in long-segment stenosis (>4 cm). High anastomotic tension may lead to anastomotic dehiscence, which is a serious and possibly fatal complication. Other risks include glottic airway edema or vocal fold paralysis due to proximity of anastomosis to the vocal folds or injury to the recurrent laryngeal nerves (RLN), respectively. LTP is an alternate technique for open airway management when the stenosis is not amenable to primary resection and anastomosis.2 LTP is preferred in cases of long-segment or multilevel stenosis, infraglottic involvement, or when primary resection is not possible due to excessive anastomotic tension. LTP does not require dissection lateral or posterior to the trachea, thus decreasing the risks of RLN or esophageal injury. However, LTP is a multistage surgery with often the need to maintain a stent such as a T-tube between stages. Additional limitations include decreased efficacy in addressing high-grade stenoses, risk for persistent anterior wall collapse, and poor mucociliary clearance. In this report, we highlight a unique hybrid surgery technique combining the respective benefits of both primary resection with anastomosis and LTP. The hybrid procedure is best suited for the management of complex long-segment or multilevel airway stenosis that is not optimally treated with either procedure alone. In the proposed technique, high-grade subglottic or proximal tracheal stenosis is treated with resection and anastomosis, and the remaining tracheal stenosis, the tracheostoma site, or tracheomalacia are treated with the LTP technique. This leads to better results than using either surgical approach individually and successful long-term decannulation of the tracheostomy-dependent patient. The hybrid procedure commences with airway assessment using suspension direct laryngoscopy and bronchoscopy under general anesthesia. The patient is ventilated via a flexible endotracheal tube through the existing tracheostomy site. The length and severity of stenosis are determined to plan for resection and anastomosis. The neck is prepared and draped in standard fashion for open airway surgery. A horizontal cervical incision incorporating the existing tracheostomy is made. Subplatysmal flaps are raised from the thyroid cartilage to clavicle. Dissection is performed in the midline to divide and lateralize the strap muscles. The thyroid gland is divided in the midline and the laryngotracheal complex is skeletonized from the thyroid cartilage to the sternal notch. Substernal pre-tracheal dissection is performed bluntly with finger dissection, or mediastinoscopy when needed, to mobilize the trachea. Intraoperative flexible bronchoscopy is performed to identify the superior level for airway resection. Ideally, the airway stenosis is managed by primary resection and anastomosis. The decision to perform a hybrid procedure depends on the surgeon's comfort and experience with long-segment resection and mobility of the trachea for tension-free anastomosis. If tension-free anastomosis cannot be achieved after tracheal mobilization and other release maneuvers, hybrid procedure is performed. The high-grade stenosis is resected and anastomosed, and the remaining stenotic tracheal segment is treated with tracheoplasty (Video 1). The tracheoplasty is a staged procedure that incorporates the existing tracheostomy site. The involved anterior tracheal stenosis is incised vertically. Then, the superior and inferior skin flaps are advanced and approximated to the tracheal edges using interrupted 3-0 polyglactin (Vicryl®) half-mattress sutures. The patient is admitted for postoperative airway management for one week to allow anastomosis maturation. A secondary procedure may be performed to place a T-tube stent spanning the LTP stoma and extending superiorly to the subglottis, which allows for phonation as the airway matures during the healing phase. The anterior wall is reconstructed in multiple layers about 3–6 months when the stoma has matured (Figs. 1 and 2). Two illustrative cases are presented below. A 56-year-old female with a complex medical history, including kidney transplantation, coronary artery disease, type 2 diabetes mellitus, and obesity was referred for airway management. She had required prolonged intubation followed by tracheostomy due to COVID19 pneumonia. She was decannulated after 3 months but required urgent second tracheostomy several months later due to interval development of airway stenosis. She subsequently failed four endoscopic treatments (CO2 laser resection, balloon dilation, steroid injection, and mitomycin C application). Airway assessment under anesthesia revealed grade 4 subglottic stenosis and a long-segment tracheal stenosis to the tracheostomy site, with a total length of 5.5 cm. The anterior tracheal wall had poor structural integrity due to the two prior tracheotomies. Due to the history of COVID-19, there was significant scarring of the airway to the mediastinum, resulting in poor mobilization of the trachea despite mediastinoscopy and mediastinal release. As the trachea could not be adequately mobilized to allow resection of entire segment from subglottis to tracheostomy site for primary anastomosis, the hybrid procedure was utilized. A 2.5-cm section of subglottis and trachea was resected primarily and anastomosed and LTP was performed for the remaining 2-cm segment of stenotic cervical trachea. One week later, a No. 11 T-tube stent (Boston Medical Products, Boston, MA) was placed. The final stage, involving the closure of the LTP stoma, was performed 6 months later (Figure 3). A 40-year-old female with a 10-year history of shortness of breath presented with acute dyspnea and was diagnosed with critical grade 3 subglottic stenosis. She underwent endoscopic dilation, but a tracheostomy was also performed due to tissue friability and edema. Over the next 3 years, she underwent five more failed endoscopic airway procedures (CO2 laser excision, balloon dilation, steroid injection, and topical mitomycin C application). She was then referred for open airway surgery. Operative endoscopy revealed high subglottic and tracheal grade 3 stenosis spanning 5 cm and involving the tracheostomy stoma. CTR was performed to address 2.5 cm of proximal grade 3 stenosis. The distal 2.5-cm stenosis spanning the length of her tracheostomy site underwent tracheoplasty. A tracheostomy tube was replaced. A T-tube was not placed due to the proximity of the CTR anastomosis to the vocal folds and postoperative edema. CTR site was patent and healed at 3 months postoperatively (Figure 4) and LTP stoma closure was performed at 6 months (Figure 2). Complex long-segment and high-grade airway stenoses are challenging to treat successfully. Ching et al. suggested that CTR and LTP have equivalent rates of decannulation. However, only short-segment stenoses were managed with CTR in that study.3 Other methods of airway augmentation without stent placement have been trialed, such as laryngotracheoplasty with costal cartilage graft.4 While this technique has been well-established in pediatric airway surgery, costal cartilage grafts in adult airway stenosis have demonstrated poor results, with patients either requiring intraoperative tracheostomy due to glottal edema or postoperative poor functional voice outcomes.4 The hybrid procedure highlighted here is applicable to treating complex long-segment stenosis where primary resection with anastomosis is not possible. This increases the efficacy compared to either CTR/TR or LTP alone. The high-grade subglottic or proximal tracheal stenosis is managed with primary resection with anastomosis, and the more distal tracheal stenosis and tracheostoma are managed with LTP. Resection techniques are more effective than LTP for the areas of high-grade stenosis. LTP approach works best for long-segment stenosis with poor structural integrity of the anterior tracheal wall. Securing the tracheal edges to the skin at the tracheoplasty site has the secondary benefit of reducing anastomotic tension at the resection site, thus reducing the risks of postoperative dehiscence or future restenosis at the anastomosis. The hybrid procedure also allows anterior collapse to be addressed in the second stage of the procedure. The senior author has used the LTP closure technique described here for management of complex long-segment stenosis for over two decades.2 The hybrid procedure is a similar multistaged procedure, but the addition of primary resection with anastomosis ultimately results in a final airway lumen much superior to that achieved from LTP alone. The hybrid procedure is effective in maintaining near-normal airway patency, and allowing for decannulation of the tracheostomy-dependent patient with high-grade long- or multilevel stenosis and is a useful technique in the airway surgeon's armamentarium.