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A New Endoscopic Technique for Intraluminal Repair of Posterior Tracheal Laceration

2010; Elsevier BV; Volume: 90; Issue: 2 Linguagem: Inglês

10.1016/j.athoracsur.2009.08.056

1552-6259

Stefan Welter, Jan Jacobs, Thomas Krbek, Raimund Halder, Georgios Stamatis,

Head and Neck Surgical Oncology

This report describes an endoscopic repair of a tracheal tear with a newly developed optical needle holder. No surgical access was necessary. A 71-year-old woman with a 5-cm gaping iatrogenic tracheal laceration and a distinctive mediastinal and subcutaneous emphysema was successfully repaired with an endotracheal running suture through a 14-mm rigid tracheoscope. Operation time was 105 minutes, and borderline jet ventilation was used to maintain oxygen saturation. A bronchoscopy 9 days later revealed the tracheal tear had completely closed and the running suture was in place. No postoperative complications were noted. This report describes an endoscopic repair of a tracheal tear with a newly developed optical needle holder. No surgical access was necessary. A 71-year-old woman with a 5-cm gaping iatrogenic tracheal laceration and a distinctive mediastinal and subcutaneous emphysema was successfully repaired with an endotracheal running suture through a 14-mm rigid tracheoscope. Operation time was 105 minutes, and borderline jet ventilation was used to maintain oxygen saturation. A bronchoscopy 9 days later revealed the tracheal tear had completely closed and the running suture was in place. No postoperative complications were noted. Mr Halder discloses that he has a financial relationship with Karl Storz GmbH. Mr Halder discloses that he has a financial relationship with Karl Storz GmbH. Tracheal laceration is a rare direct complication of endotracheal intubation. It most often includes the posterior wall in the midline or right paramedian. Early surgical treatment will prevent the potentially lethal complications of mediastinitis and tracheal stricture [1Orta D.A. Cousar J.E. Yergin B.M. Olsen G.N. Tracheal laceration with massive subcutaneous emphysema: a rare complication of endotracheal intubation.Thorax. 1979; 34: 665-669Crossref PubMed Scopus (38) Google Scholar]. Although some authors advise nonsurgical management for small tears in hemodynamically stable patients without pneumomediastinum, without mediastinitis, without esophageal injury, and without difficulty in ventilation [2Gagermeier J.P. Non-surgical management of tracheal laceration.Chest. 2004; 126: 943Google Scholar], other authors recommend surgical repair through tracheostomy access [3Okada S. Ishimori S. Yamagata S. Satoh S. Tanaba Y. Yaegashi S. Videobronchoscope-assisted repair of the membranous tracheal laceration during insertion of a tracheostomy tube after tracheostomy.J Thorac Cardiovasc Surg. 2002; 124: 837-838Abstract Full Text Full Text PDF PubMed Scopus (5) Google Scholar], transcervical access with a tracheotomy [4Park K. Lee J.G. Lee C.Y. Kim D.J. Chung K.Y. Transcervical intraluminal repair of posterior membranous tracheal laceration through semi-lateral transverse tracheotomy.J Thorac Cardiovasc Surg. 2007; 134: 1597-1598Abstract Full Text Full Text PDF PubMed Scopus (8) Google Scholar, 5Angelillo-Mackinlay T. Transcervical repair of distal membranous tracheal laceration.Ann Thorac Surg. 1995; 59: 531-532Abstract Full Text PDF PubMed Scopus (58) Google Scholar], or a right posterolateral thoracotomy [6Carbognani P. Bobbio A. Cattelani L. Internullo E. Caporale D. Rusca M. Management of postintubation membranous tracheal rupture.Ann Thorac Surg. 2004; 77: 406-409Abstract Full Text Full Text PDF PubMed Scopus (102) Google Scholar, 7Sippel M. Putensen C. Hirner A. Wolff M. Tracheal rupture after endotracheal intubation: experience with management in 13 cases.J Thorac Cardiovasc Surg. 2006; 54: 51-56Crossref Scopus (39) Google Scholar]. Kouerinis and colleagues [8Kouerinis I. Loutsidis A. Hountis P. Apostolakis E. Bellenis I. Treatment of iatrogenic injury of membranous trachea with intercostal muscle flap.Ann Thorac Surg. 2004; 78: 85-86Abstract Full Text Full Text PDF PubMed Scopus (8) Google Scholar] even recommend the use of an intercostal muscle flap. All these methods are described as being effective, but they all require some sort of surgical access. In this article we report indications, technique, and results after an exclusively endoluminal repair without a surgical access. The newly developed optical needle holder (Karl Storz Endoscopes, Tuttlingen, Germany) devise, which is still in development, allows a tracheal laceration to be repaired under visual control. A rigid Hopkins telescope can be fixed in the needle holder. A special ratchet facilitates the needle to be securely fixed in the jaws when the handle is closed. The Hopkins telescope is a rigid rod lens telescope with a 12° angle of view. The telescope has an outer diameter of 4 mm and the working length is 30 cm. This new optical needle holder can be used with a 14-mm tracheoscope (Fig 1). After a 2-week treatment for bilateral pneumonia at another institution, the patient, a 71-year-old woman, was found nonresponsive in the early morning because of carbon dioxide (CO2) retention. Her medical history included severe obstructive lung emphysema and diabetes mellitus type 2. After emergency intubation, ventilation was difficult due to a relevant air leak around the tubus cuff. A left sided pneumothorax was drained, and a computed tomography (CT) scan was obtained of the chest area where the tracheal laceration was suspected (Fig 2). A transfer to our clinic was organized immediately so that the tracheal repair could be started 7 hours after the injury. We admitted the intubated patient, who had distinctive subcutaneous and mediastinal emphysema. A rigid bronchoscopy revealed a 5-cm posterior tracheal wall injury (Fig 3). The repair began with the introduction of a 14-mm rigid tracheoscope just below the vocal cords and the start of the jet ventilation. Blood and secretions were cleared with suction. The first stitch with the optical needle holder using a 70-cm, 3-0 Vicryl suture (UCLX-needle; Ethicon, Norderstedt, Germany) started distally, catching the whole posterior wall (Fig 4). The end of the thread was armed with a small absorbable polydioxanone clip (ABSOLOK AP100, Ethicon). With the thread held under tension, a running suture could be applied. After each stitch, the needle had to be pulled out and introduced again with the needle holder. Because of the jet ventilation, a sharp plane between the tracheal membrane and the esophagus was visible. After the last stitch, another polydioxanone clip was applied to keep the suture under tension. The thread end was cut and removed. The procedure was transmitted by a video camera and was visible on a monitor. Operation time was 105 minutes, with several interruptions to reoxygenate the patient when oxygen saturation dropped below 90% (lowest partial pressure of arterial oxygen was 51 mm Hg). After complete closure of the tear, a single-lumen tubus was placed in the position of the repair with the cuff slightly inflated. Extubation followed 26 hours later when the partial pressure of CO2 dropped below 60 mm Hg. Broad-spectrum antibiotics were applied to prevent mediastinitis, and no further drainage was introduced. Because of severe obstructive emphysema with respiratory insufficiency, this patient needed long-term noninvasive positive airway pressure support by a ventilation mask at least 21 hours daily. A follow-up bronchoscopy 9 days later revealed the tracheal tear completely closed and the running suture was in place. No further subcutaneous emphysema and no inflammatory problems were recognized. This exclusively endotracheal repair avoided a surgical access with corresponding morbidity. We expect that operation time will be reduced with growing experience. The necessity to repeatedly clear blood from the site, the rigid tracheoscope with the limited freedom of movement, and the jerky movements of the operation field induced by jet ventilation made the suture difficult to perform. A technical limitation of the method might be an eccentric tear without a strip of membranous posterior wall at the right border. With a newly developed optical needle holder, an exclusively endoluminal repair of a longitudinal tracheal laceration is possible, but we are at the beginning of the learning curve. We thank the Karl Storz Company for developing the new device and providing it for our use.