ABSTRACT
BACKGROUND: Tracheal stenosis and tracheo-esophageal fistulas are serious but rare complications of prolonged invasive mechanical ventilation. Tracheal resection with end-to-end anastomosis and endoscopic procedure are the options of care in the treatment of tracheal injuries. Tracheal stenosis could be iatrogenic, associated with tracheal tumors, or idiopathic. Tracheo-esophageal fistula may be congenital or acquired; in adults about half of the cases are secondary to malignancies. METHODS: We performed a retrospective study of all the patients referred to our center between 2013 and 2022, with diagnosis of benign or malign tracheal stenosis or tracheo-esophageal fistulas due to benign or malign airway injury, undergoing tracheal surgery. Patients are divided in two temporal cohorts: cohort X if treated before SARS-CoV-2 pandemic (from 2013 to 2019) and cohort Y if treated during and after SARS-CoV-2 pandemic (from 2020 to 2022). RESULTS: From the onset of the COVID-19 outbreak, we experienced an unprecedented increase in the incidence of TEF and TS. In addition, based on our data, results show less variability for TS etiology, mainly iatrogenic, an increase of 10 years in median age and an inversion of trend regarding the sex of patients. CONCLUSIONS: The standard of care for definitive treatment of TS is tracheal resection and end-to-end anastomosis. Literature shows a high success rate (83-97%) and low mortality (0-5%) following surgery in specialized centers with experience. Management of tracheal complication after prolonged MV is still challenging. An adequate clinical and radiological follow-up should be performed in patients treated with prolonged MV in order to diagnose any tracheal lesions in the subclinical phase and to choose the correct strategy, center and time to treat it.
ABSTRACT
BACKGROUND: Since December 2019, Sars-CoV2 infection has become a pandemic health emergency. The most severe manifestation of Covid-19 is acute respiratory distress syndrome requiring intensive care unit admission and mechanical ventilation. The most serious, although rare, complication of prolonged MV is post-intubation tracheal stenosis. We hypothesized that, in addition to recognized risk factors in Covid-19 patients, additional factors may promote airways injury. METHODS: We analyzed data from 13 patients with PITS referred to our Thoracic Surgery Department from 2020 to 2022 divided in two groups: 8 ex-Covid-19 patients (in MV for ARDS during Sars-Cov2 positivity) and 5 non-Covid-19 patients (in MV for other reasons). Computer-tomography and bronchoscopy were performed to confirm diagnosis of PITS. Surgical treatment including tracheal resection and end-to-end anastomosis was performed in all patients. Tracheal samples were histologically analyzed to define the existence of any difference between the two groups. RESULTS: The presence of total immunoglobulin G (IgG) and immunoglobulin G4 (IgG4) were tested. IgG infiltrate was present in both groups. IgG4-infiltrate was significantly represented in the tracheal sample of ex-Covid-19 patients and absent in the non-Covid-19 cohort of patients. CONCLUSIONS: It is suggested that Covid-19 patients have almost double the risk of developing tracheal injuries. This work supports the idea of a major predisposition for such injuries in Covid-19 patients due to a possible immune-mediated mechanism leading to aberrant and fibrotic wound healing following a trigger insult (in this case MV with oro-tracheal tube). In the near future an increasing incidence of PITS is expected. Interventional pulmonologist and thoracic surgeons might be called to deal with this possibility. Clarification of the physiopathology of PITS is needed to prevent excessive tracheal scarring following prolonged endotracheal intubation and recurrence after endoscopic and/or surgical treatment. Careful prevention, early detection and effective management of this life-threatening condition are warranted.