Observation of Synchronous Primary Multiple Carcinoid of the Trachea and Main Bronchus

Carcinoid tumors are rare malignant neoplasms of the respiratory system. They belong to neuroendocrine tumors with a low degree of (G1, G2) malignancy. Even less common is the primary multiplicity of these tumors in the trachea and bronchi, which can complicate the only radical, surgical treatment. We present an observation of a 75-year-old patient who was able to diagnose a carcinoid of the cervical trachea and left main bronchus in a timely manner, determine the exact localization and prevalence of the tumor, and successfully conduct surgical treatment in 2 stages.

Experience of Emergency Cervical Tracheal Repair after Non-Iatrogenic Injury

Background: Non-iatrogenic cervical tracheal injury is very rare and challenging for emergency critical care, early diagnosis, and immediate repair. So, emergency repair after early definitive diagnosis is the mainstay to avoid mortality and morbidity. Methods: A retrospective, observational, cohort study is undertaken with collected data on 50 patients with emergency cervical tracheal repair after non-iatrogenic injury between January 2011 to January 2020 at our accident and emergency department in Minia and South Valley Universities. Results: The non-iatrogenic injury of the cervical trachea is more common in adult males (98%), and blunt trauma (70%) is the predominant type of injury. Subcutaneous emphysema (SE) is the most common presentation (99%). There are associated comorbidities like vascular (4%), maxillofacial (6%), head injury (2%), and esophageal tear (8%). Successful intubation is lifesaving, and early diagnosis and repair avoid complications. Conclusions: Early diagnosis is a cornerstone for the successful management of cervical tracheal injury, in which successful intubation is a mainstay to reduce mortality. Emergency surgical repair reduces mortality and complications.

Pilot Study of Trans-oral Robotic-Assisted Needle Direct Tracheostomy Puncture in Patients Requiring Prolonged Mechanical Ventilation

COVID-19 can induce severe respiratory problems that need prolonged mechanical ventilation in the intensive care unit. While Open Tracheostomy (OT) is the preferred technique due to the excellent visualization of the surgical field and structures, Percutaneous Tracheostomy (PT) has proven to be a feasible minimally invasive alternative. However, PT's limitation relates to the inability to precisely enter the cervical trachea at the exact spot since the puncture is often performed based on crude estimation from anatomical laryngeal surface landmarks. Besides, there is no absolute control of the trajectory and force required to make the percutaneous puncture into the trachea, resulting in inadvertent injury to the cricoid ring, cervical esophagus, and vessels in the neck. Therefore, we hypothesize that a flexible mini-robotic system, incorporating the robotic needling technology, can overcome these challenges by allowing the trans-oral robotic instrument of the cervical trachea. This approach promises to improve current PT technology by making the initial trachea puncture from an “inside-out” approach, rather than an “outside-in” manner, fraught with several technical uncertainties.

Tracheal Agenesis: Vertical Division of the Native Esophagus – A Novel Surgical Approach and Review of the Literature

Introduction: Tracheal agenesis (TA) is rare and usually fatal. Few survivors with concomitant tracheoesophageal fistulae (TEF) who underwent ligation of the distal esophagus with creation of a spit-fistula and neo-trachea from the proximal esophagus exist. We report a novel surgical technique whereby the esophagus is divided longitudinally to preserve a functional alimentation tract and a parallel neo-trachea. We review the literature of reported cases, including survivors beyond 12 months. Methods: Case report and literature review. Results: A female infant with prenatal polyhydramnios was born at 35 weeks gestation with immediate respiratory distress and absent cry. Oxygenation was maintained with a laryngeal mask airway. Despite a normal appearing larynx, she could not be intubated and emergent neck exploration disclosed no cervical trachea. The patient was placed on extra corporeal membranous oxygenation (ECMO), and later diagnosed with TA, Floyd Type I. Parental desire for reconstruction but refusal of a spit-fistula necessitated a novel procedure. The esophagus was divided longitudinally via a microstapler to preserve the original alimentary tract and create a parallel neo-trachea originating from the TEF and terminating as a cervical stoma. The healing process was complicated but the baby was ultimately discharged to home where she developed normally neurologically until succumbing one night to accidental decannulation at 16 months of age. Conclusion: We describe a novel surgical approach to manage TA. This includes avoiding creation of a spit fistula and preserving the native esophagus. We then survey the literature, reporting the survivorship duration and operative management of 174 reported cases of TA.

Treatment with Hyaluronic Acid and Collagen-Polyvinylpyrrolidone Improves Extracellular Matrix Assembly for Scarring after Tracheal Resection

Treatment of tracheal stenosis is occasionally performed in combination with wound healing modulators to manipulate new extracellular matrix (ECM) formation and prevent fibrosis. Hyaluronic acid (HA) and collagen-polyvinylpyrrolidone (collagen-PVP) decrease fibrosis in experimental tracheal healing. However, they have not been used clinically as their effect on ECM components, which modify tracheal scarring, has not been described. Objective. To evaluate the effect of the application of HA, collagen-PVP, a mixture of HA and collagen-PVP (HA+collagen-PVP), and mitomycin C on the expression of decorin, matrix metalloproteinase 1 (MMP1), and MMP9, as well as the type of collagen and deposits formed in the scar after resection and end-to-end anastomosis (REEA) of the cervical trachea using an experimental model. Materials and Methods. Thirty dogs underwent REEA of the cervical trachea and were treated with different wound healing modulators: group I (n=6), control; group II (n=6), HA; group III (n=6), collagen-PVP; group IV (n=6), HA+collagen-PVP; and group V (n=6), mitomycin C. The dogs were evaluated clinically and endoscopically for 4 weeks. Subsequently, macroscopic and microscopic changes, expression of ECM proteins, and collagen deposition in tracheal scars were analysed. Results. Groups II, III, and IV showed reduced endoscopic, macroscopic, and microscopic inflammation, improved neovascularization, high decorin expression (p<0.01, analysis of variance (ANOVA)), and moderate expression of MMP1 (p<0.003, ANOVA) and type I and III collagen (p<0.05, Kruskal–Wallis). Groups IV and V developed fewer collagen deposits (p<0.001, ANOVA). Conclusion. Treatment with HA and collagen-PVP improved post-REEA healing by increasing neovascularization, stimulating the expression of decorin, and regulating the expression of MMP1, as well as type I and III collagen and their deposition.

Comparison of Endoscopic and Ultrasonographic Measurements of the Subglottic Airway in Children

Objective To compare measurements of the pediatric subglottis obtained by surgeon-performed ultrasound and endoscopy. Study Design Prospective observational comparison-of-methods study. Setting Tertiary care pediatric hospital. Subjects and Methods Thirty-one patients who underwent direct laryngoscopy from May 2017 to July 2018 were recruited. Transcervical ultrasound was used to visualize the vocal folds, subglottis, and cervical trachea. The anterior-posterior (AP) and transverse (TV) diameter of the subglottic space were measured endoscopically and via ultrasound by 2 independent evaluators. Measurements were compared for correlation, bias, and agreement. A clinically acceptable bias for subglottic diameter was assumed to be 0.5 mm or less. Results The median age of enrolled patients was 2.6 years (range, 4 months–13.3 years). Endoscopic subglottic AP and TV measurements ranged from 3.33 mm to 14.81 mm and from 4.44 mm to 11.65 mm, respectively, while ultrasonographic AP and TV measurements ranged from 4.57 mm to 9.85 mm and from 3.77 mm to 8.96 mm. Pearson coefficient showed strong a correlation for both endoscopic and ultrasound AP ( R = 0.8081, P < .0001) and TV ( R = 0.8796, P < .001) measurements of the subglottis. Bland-Altman plots revealed a bias (average discrepancy) for AP measurements of 0.22 mm and 0.11 mm for TV measurements. Conclusion Endoscopic and ultrasonography measurements of the pediatric subglottic airway were strongly correlated. The discrepancy between AP and TV measurements was less than 0.5 mm. Ultrasound of the subglottis may be an alternative to endoscopic assessment of the airway for measurement of the subglottic airway in children in select cases.

Microsurgery of chronic post-intubation laryngeal stenosis using a CO2-laser

Introduction. Despite significant progress achieved in the surgical treatment of cicatricial laryngeal stenosis and cervical trachea in recent decades, this issue appears relevant, especially among people of young and working age.Aim of the study: To develop tactics for surgical treatment of post-intubation laryngeal stenosis using a CO2-laser.Materials and methods: During the period from 2015 to 2019, surgical treatment was performed for 105 patients with post-intubation cicatricial stenosis of the larynx using microsurgical techniques and a CO2-laser, provided that the cartilage frame of the larynx was preserved, which was determined in a preoperative examination.Results and discussion: In the postoperative period, patients were monitored from 6 months to 3 years. Localization of cicatricial post-intubation laryngeal stenosis in the vestibular region is quite rare. According to the results of the study, achievement of a stable functional result was obtained in 20 (84%) of 24 patients with lesions of the vocal section of the larynx, in one case a cicatricial membrane of this section of the larynx was required to be excised after one year, and laryngoplasty with extra laryngeal access in four cases. Post-intubation stenosis of sub-folded localization is most widespread, and in our observations they amounted to 79%. The use of endolaryngeal access using a CO2-laser made it possible to achieve a good functional result in 66% of cases, reconstruction of the larynx by extra-laryngeal access was required in 33%, and laryngotracheal resection in 1%.Conclusion: It is shown that the use of a CO2-laser in the surgical treatment of chronic post-intubation laryngeal stenosis significantly expands operational capabilities due to the high accuracy and low level of damage to surrounding tissues. This method allows the formation of minimal wound surfaces by submucosal excision of scar tissue and makes it possible to cover the wound with microlosks of the mucous membrane, reducing the time of epithelization in the intervention area, which is an important prevention of repeated stenosis. In the surgical treatment of extended stenosis of the middle part of the larynx, there are prerequisites for repeated wound replacement with scar tissue, which in our observations was avoided by using endoprostheses. The defeat of the sub-follicular part of the larynx is prone to restenosis even in the absence of data for the defeat of the cartilaginous framework of the larynx.