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Reinforcement of an end-to-end tracheal resection anastomosis with fibrin glue: A case report.

Abstract

Tracheal resection and primary anastomosis is the treatment of choice for a short-segment stenosis. However, the procedure does carry the risk of two potentially fatal complications: anastomosis breakdown and leak. We describe the case of a 67-year-old man who was treated for a 3-cm tracheal stenosis secondary to a prolonged intubation and multiple tracheostomies. The patient underwent a tracheal resection and primary anastomosis. The anastomosis was reinforced with fibrin sealant, which created an airtight seal. The patient was extubated postoperatively, and he healed without complication. Fibrin sealant is a convenient, safe, and effective material for reinforcing anastomotic suture lines.

Introduction

Postintubation tracheal injury is the most common indication for tracheal resection and reconstruction. Common postoperative complications include suture-line granulation, dehiscence of the anastomosis, restenosis, vocal fold paralysis, tracheomalacia, hemorrhage, and infection. The incidence of one of these complications--suture-line granuloma--has decreased since the use of absorbable synthetic sutures (e.g., Vicryl) and the submucosal placement of sutures has become more commonplace. [1] The incidence of the other complications has remained constant.

Case report

A 67-year-old man who experienced a tracheal stenosis after a prolonged intubation and tracheostomy decannulation came to the otolarynogology service with a complaint of stridor at rest. A head and neck examination revealed the presence of a well-healed tracheostomy scar. Flexible fiberoptic laryngoscopy revealed that both vocal folds were mobile. Computed tomography of the neck revealed a proximal tracheal stenosis. Flexible bronchoscopy demonstrated tracheomalacia and a collapse of the trachea at the stenotic segment (figure 1). The patient was scheduled for a diagnostic rigid bronchoscopy and primary resection and repair of the tracheal stenosis.

Intraoperatively, the rigid bronchoscopy revealed the presence of a 2.5-cm proximal stenotic segment (figure 2). The patient underwent orotracheal intubation, neck exploration, and tracheal dissection. The stenotic segment was isolated. It involved the distal cricoid icoid cartilage and proximal trachea (Grillo type II). The stenotic segment was circumferentially mobilized and resected. The orotracheal tube was replaced with a tracheal tube through the neck incision. The posterior wall was reconstructed with interrupted Vicryl sutures (figure 3). After the posterior wall was repaired, the patient was reintubated orotracheally and the anterior wall was repaired with interrupted Vicryl sutures. The suture line was reinforced with fibrin glue laced with gentamicin (figure 4). The strap muscles were closed at the midline, and the skin was closed after the subcutaneous space was drained. A neck flexion stitch was applied, and the patient was extubated.

Postoperative bronchoscopy showed a good airway with no granulation tissue. Ten months postoperatively, the patient still maintained a good airway (figure 5).

Discussion

Tracheal resection and anastomosis is a technically difficult operation that carries the risk of life-threatening complications, including suture-line dehiscence, innominate artery erosion, and wound infection. [1-6] Grillo et al reported a large series in which the incidence of tracheal wound dehiscence or tracheal stenosis was 2.2% for tracheotracheal anastomoses, 6.1% for cricotracheal anastomoses, and 8.0% for thyrotracheal anastomoses. [1] They also reported that innominate artery erosion occurred in five of their 503 patients (1.0%), three of whom died (0.6%), and that major wound infections occurred in 15 patients (3.0%).

Reinforcing the suture line with fibrin glue adds strength to the line, creates an airtight seal, isolates the innominate artery from the anastomosis, and provides a medium for the local delivery of antibiotics.

Fibrin sealant (Tisseel; Baxter Healthcare Corp.; Glendale, Calif.) contains fibrinogen (a sealer protein) as its main active ingredient. It also contains thrombin, calcium chloride, and a fibrinolysis inhibitor (aprotinin). The two reconstituted components--the sealer protein and the thrombin solutions--are mixed and applied topically. Mixing the sealer protein and the thrombin solutions produces a viscous solution that forms an elastic coagulum when it sets. Thrombin is a highly specific protease that transforms the fibrinogen contained in the sealer protein concentrate into fibrin. The thrombin is partly adsorbed by the fibrin that is so formed. Excess thrombin, if any, is inactivated by protease inhibitors in the blood.

Takahashi et al used tissue glue and fascia lata to reinforce tracheal anastomosis suture lines in dogs. [7] They found that this procedure prevented air from leaking from the suture line and decreased morbidity. Fibrin glue was also used by Gutierrez et alto repair persistent or recurrent tracheoesophageal fistulae. [8] Seguin et al used fibrin glue to repair type A aortic dissections in humans with good results. [9] Detweiler et al achieved normal small bowel and colon anastomoses in animals with fibrin glue and an absorbable endoluminal stent. [10]

Some potential complications of fibrin glue include a patient's hypersensitivity to its various components, the introduction of bacteria at the surgical site by the fibrin coagulum, and the transmission of blood-borne viruses. The risk of bacterial invasion is reduced by the addition of antibiotics to the glue. [11] The risk of viral transmission is minimized during the Tisseel manufacturing process, which incorporates a two-step vapor-heating process that inactivates viruses.

In conclusion, given the potential devastating complications of suture dehiscence and wound infection and the apparent safety of fibrin glue, we believe that fibrin glue appears to be a worthwhile method of reinforcing a tracheal anastomosis line. It reduces the risk of leaks, anastomosis dehiscence, innominate erosion, and wound infection. Even so, a large prospective study is needed to confirm its efficacy.

References

(1.) Grillo HC, Donahue DM, Mathisen DJ, et al. Postintubation tracheal stenosis. Treatment and results. J Thorac Cardiovasc Surg 1995; 109:486-92.

(2.) Laccourreye O, Naudo P, Brasnu D, et al. Tracheal resection with end-to-end anastomosis for isolated postintubation cervical trachea stenosis: Long-term results. Ann Otol Rhinol Laryngol 1996; 105:944-8.

(3.) Wood DE, Vallieres E. Tracheobronchial resection and reconstruction. Arch Surg 1997; 132:850-4.

(4.) Grillo HC, Donahue DM. Postintubation tracheal stenosis. Chest Surg Clin N Am 1996; 6:725-31.

(5.) Adelsmayr E, Keller C, Erd G, Brimacombe J. The laryngeal mask and high-frequency jet ventilation for resection of high tracheal stenosis. Anesth Analg 1998; 86:907-8.

(6.) Tsubota N, Yoshimura M, Miyamoto Y, et al. Primary anastomosis of the trachea: Management and pitfalls. Surg Today 1998; 28:492-7.

(7.) Takahashi N, Ichimiya Y, Mawatari T, et al. The reinforcement of tracheoplasty with a self-fascia lata and Gelatin-Resorcin-Formal (GRF) glue. Surg Today 1997; 27:1046-50.

(8.) Gutierrez C, Barrios JE, Lluna J, et al. Recurrent tracheoesophageal fistula treated with fibrin glue. J Pediatr Surg 1994; 29:1567-9.

(9.) Seguin JR, Picard E, Frapier JM, Chaptal PA. Repair of the aortic arch with fibrin glue in type A aortic dissection. J Card Surg 1994; 9:734-8.

(10.) Detweiler MB, Durastante V, Verbo A, et al. Sutureless anastomosis of the small intestine and the colon in pigs using an absorbable intraluminal stent and fibrin glue. J Invest Surg 1995; 8:129-40.

(11.) Thompson DF, Davis TW. The addition of antibiotics to fibrin glue. South Med J 1997; 90:681-4.
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Comment:Reinforcement of an end-to-end tracheal resection anastomosis with fibrin glue: A case report.
Author:Huo, Jerry
Publication:Ear, Nose and Throat Journal
Geographic Code:1USA
Date:Apr 1, 2001
Words:1142
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