Tracheal resection in patients post-COVID-19 is associated with high reintervention rate and early restenosis.

Objectives: A remarkable increase in the number of patients presenting with tracheal complications after prolonged endotracheal intubation and mechanical ventilation for the management of the severe COVID-19-associated respiratory failure has been observed. In this study, we assessed the postoperative outcomes of tracheal resection in patients with COVID-19. Methods: We conducted a retrospective study in which all patients with a history of prolonged invasive mechanical ventilation due to COVID-19 infection, who were treated with tracheal resection and reconstruction, were included. The primary objective was in-hospital mortality and postoperative reintervention rate. The secondary objective was the time to tracheal restenosis. Results: During the 16-month study period, 11 patients with COVID-19 with tracheal complications underwent tracheal resection with end-to-end anastomosis. Mean patient age was 51.5 ± 9 years, and the majority were male (9 patients). Eight patients were referred for management of postintubation tracheal stenosis, and 3 patients were referred for tracheoesophageal fistula. Eight patients had a history of tracheostomy during the COVID-19 infection hospitalization. There was 1 in-hospital death (9.1%) due to septicemia in the intensive care unit approximately 2 months after the operation. Postoperatively, 32 reinterventions were required for tracheal restenosis due to granulation tissue formation. The risk for reintervention was higher during the first 3 months after the index operation. Four patients developed tracheal restenosis (36.4%), and 2 of them required endotracheal stent placement during the follow-up period. Conclusions: Tracheal resection and reconstruction after COVID-19 infection are associated with a high reintervention rate postoperatively. Such patients require close follow-up in expert interventional pulmonology units, and physicians should be on high alert for the early diagnosis and optimal management of tracheal restenosis.

[Treatment of post-intensive care tracheal stenosis after previous covid-19 pneumonia]. / Lechenie postreanimatsionnykh rubtsovykh stenozov trakhei posle perenesennoi koronavirusnoi pnevmonii Covid-19.

OBJECTIVE: To analyze postoperative outcomes and perioperative management of patients with post-intensive care tracheal stenosis and previous COVID-19 pneumonia. MATERIAL AND METHODS: There were 8 patients with post-intensive care tracheal stenosis and previous COVID-19 pneumonia aged 34-61 years between January 2021 and April 2021. Lung damage CT-3 was observed in 2 (25%) patients, CT-4 - in 5 (62.5%) patients. In one case, COVID-19 pneumonia with lung damage CT-2 joined to acute cerebrovascular accident. Post-tracheostomy stenosis was detected in 7 (87.5%) cases, post-intubation stenosis - in 1 patient. Duration of invasive mechanical ventilation ranged from 5 to 130 days. In 75% of cases, tracheal stenosis was localized in the larynx and cervical trachea. Two patients admitted with tracheostomy. In one case, an extended tracheal stenosis was combined with atresia of infraglottic part of the larynx. One patient had tracheal stenosis combined with tracheoesophageal fistula (TEF). Length of tracheal stenosis was 15-45 mm. Tracheomalacia was observed in 4 (50%) patients. All patients had severe concomitant diseases. RESULTS: To restore airway patency, we used circular tracheal resection with anastomosis, laryngotracheoplasty and endoscopic methods. Tracheal resection combined with TEF required circular tracheal resection with disconnection of fistula. Adequate breathing through the natural airways was restored in all patients. There was no postoperative mortality. Three patients with baseline tracheal stenosis had favorable postoperative outcomes after circular tracheal resection. Four patients are at the final stage of treatment after laryngotracheoplasty and tracheal stenting. CONCLUSION: Patients after invasive mechanical ventilation for COVID-19 pneumonia are at high risk of cicatricial tracheal stenosis and require follow-up. Circular tracheal resection ensures early rehabilitation and favorable functional results. Laryngotracheoplasty is preferred if circular tracheal resection is impossible. This procedure ensures adequate debridement of tracheobronchial tree and respiratory support. Endoscopic measures are an alternative for open surgery, especially for intrathoracic tracheal stenosis and intractable tracheobronchitis.

[Treatment of cicatricial tracheal stenosis and tracheoesophageal fistula in patients with COVID-19 pneumonia]. / Lechenie rubtsovogo stenoza trakhei i trakheopishchevodnogo svishcha u bol'nykh, perenesshikh COVID-19-pnevmoniyu.

OBJECTIVE: To describe treatment of cicatricial tracheal stenosis and tracheoesophageal fistula in patients with COVID-19 pneumonia. MATERIAL AND METHODS: There were 91 patients with cicatricial tracheal stenosis for the period from August 2020 to April 2022 (21 months). Of these, 32 (35.2%) patients had cicatricial tracheal stenosis, tracheoesophageal fistula and previous coronavirus infection with severe acute respiratory syndrome. Incidence of iatrogenic tracheal injury following ventilation for viral pneumonia in the pandemic increased by 5 times compared to pneumonia of other genesis. Majority of patients had pneumonia CT grade 4 (12 patients) and grade 3 (8 patients). Other ones had pulmonary parenchyma lesion grade 2-3 or mixed viral-bacterial pneumonia. Isolated tracheoesophageal fistula without severe cicatricial stenosis of trachea or esophagus was diagnosed in 4 patients. In other 2 patients, tracheal stenosis was combined with tracheoesophageal fistula. Eight (25%) patients had tracheostomy at the first admission. This rate was almost half that of patients treated for cicatricial tracheal stenosis in pre-pandemic period. RESULTS: Respiratory distress syndrome occurred in 1-7 months after discharge from COVID hospital. All patients underwent surgery. In 7 patients, we preferred palliative treatment with dilation and stenting until complete rehabilitation. In 5 patients, stent was removed after 6-9 months and these ones underwent surgery. There were 3 tracheal resections with anastomosis, and 2 patients underwent tracheoplasty. Resection was performed in 3 patients due to impossible stenting. Postoperative course in these patients was standard and did not differ from that in patients without viral pneumonia. In case of tracheoesophageal fistula, palliative interventions rarely allowed isolation of trachea. Four patients underwent surgery through cervical approach. There were difficult surgeries in 2 patients with tracheoesophageal fistula and cicatricial tracheal stenosis. One of them underwent separation of fistula and tracheal resection via cervical approach at primary admission. In another patient with thoracic fistula, we initially attempted to insert occluder. However, open surgery was required later due to dislocation of device. CONCLUSION: Absolute number of patients with tracheal stenosis, tracheoesophageal fistula and previous COVID-19 has increased by several times compared to pre-pandemic period. This is due to greater number of patients requiring ventilation with risk of tracheal injury, non-compliance with preventive protocol for tracheal injury including anti-ischemic measures during mechanical ventilation. The last fact was exacerbated by involvement of allied physicians with insufficient experience of safe ventilation in the «red zone¼, immunodeficiency in these patients aggravating purulent-inflammatory process in tracheal wall. The number of patients with tracheostomy was 2 times less that was associated with peculiarity of mechanical ventilation in SARS-CoV-2. Indeed, tracheostomy was a poor prognostic sign and physicians tried to avoid this procedure. Incidence of tracheoesophageal fistula in these patients increased by 2 times compared to pre-pandemic period. In subacute period of COVID-associated pneumonia, palliative measures for cicatricial tracheal stenosis and tracheoesophageal fistula should be preferred. Radical treatment should be performed after 3-6 months. Absolute indication for circular tracheal resection with anastomosis is impossible tracheal stenting and ensuring safe breathing by endoscopic methods, as well as combination of cicatricial tracheal stenosis with tracheoesophageal fistula and resistant aspiration syndrome. Incidence of postoperative complications in patients with cicatricial tracheal stenosis and previous mechanical ventilation for COVID-19 pneumonia and patients in pre-pandemic period is similar.

Complex Post-intubation Tracheal Stenosis in Covid-19 Patients.

Management of tracheal complications due to endotracheal intubation in patients with coronavirus disease-2019 (COVID-19) is an important concern. This study aimed to present the results of patients who had undergone tracheal resection and reconstruction due to COVID-19-related complex post-intubation tracheal stenosis (PITS). We evaluated 15 patients who underwent tracheal resection and reconstruction due to complex PITS between March 2020 and April 2021 in a single center. Seven patients (46.6%) who underwent endotracheal intubation due to the COVID-19 constituted the COVID-19 group, and the remaining 8 patients (53.4%) constituted the non-COVID-19 group. We analyzed the patients' presenting symptoms, time to onset of symptoms, radiological and bronchoscopic features of stenosis, bronchoscopic intervention history, length of the resected tracheal segment, postoperative complications, length of hospital stay, and duration of follow-up. Six of the patients (40%) were female, and 9 (60%) were male. Mean age was 43.3 ± 20.5. We found no statistically significant difference between the COVID-19 and non-COVID-19 PITS groups in terms of presenting symptoms, time to onset of symptoms, stenosis location, stenosis severity, length of the stenotic segment, number of bronchoscopic dilatation sessions, dilatation time intervals, length of the resected tracheal segment, postoperative complications, and length of postoperative hospital stay. Endotracheal intubation duration was longer in the COVID-19 group than non-COVID-19 group (mean ± SD: 21.0 ± 4.04, 12.0 ± 1.15 days, respectively). Tracheal resection and reconstruction can be performed safely and successfully in COVID-19 patients with complex PITS. Comprehensive preoperative examination, appropriate selection of surgery technique, and close postoperative follow-up have favorable results.

Post-COVID-19 airway stenosis treated by tracheal resection and anastomosis: a bicentric experience.

Objective: The COVID-19 pandemic was an extraordinary challenge for the global healthcare system not only for the number of patients affected by pulmonary disease, but also for the incidence of long-term sequalae. In this regard, laryngo-tracheal stenosis (LTS) represents one of the most common complications of invasive ventilation. Methods: A case series of patients who underwent tracheal resection and anastomosis (TRA) for post-COVID-19 LTS was collected from June 2020 to September 2021. Results: Among 14 patients included, 50% had diabetes and 64.3% were obese. During intensive care unit stay, mean duration of orotracheal intubation (OTI) was 15.2 days and 10 patients (71.4%) underwent tracheostomy, which was maintained in 7 for an average of 31 days. According to the European Laryngological Society classification, 13 patients (92.9%) had a grade IIIa LTS and one a grade IIIa+. All patients underwent Type A TRA, according to the authors' classification. No major perioperative complications were reported and at the last follow-up all patients were asymptomatic. Conclusions: With the appropriate indications, TRA represents an effective treatment in post-COVID-19 LTS patients. Short OTI times and careful tracheostomy are required in order to reduce the incidence of airway injury.

Histologic evidence of tracheal stenosis directly resulting from SARS-CoV-2 tissue infiltration, a case series.

BACKGROUND: There has been an anecdotal increase in the incidence of tracheal stenosis that has coincided with the SARS-CoV-2 pandemic. CASE PRESENTATION: This is a case series in which we report clinical and pathologic findings of two patients who subsequently developed subglottic tracheal stenosis after having been hospitalized with COVID-19 pneumonia. Histopathologic analysis of tissue from these patients shows features consistent with tissue infiltrated with SARS-CoV-2 virus, namely multinucleated syncytial cells with prominent nucleoli. CONCLUSION: Our findings directly implicate SARS-CoV-2 in the pathogenesis of tracheal stenosis.

Tracheal Stenosis After Prolonged Intubation Due to COVID-19.

OBJECTIVES: The authors aimed to evaluate the characteristics and management outcomes of patients who developed tracheal stenosis after invasive mechanical ventilation (IMV) due to COVID-19. DESIGN, SETTING, AND PARTICIPANTS: The data of 7 patients with tracheal stenosis and 201 patients without tracheal stenosis after IMV due to COVID-19 between March 2020 and October 2021 were retrospectively analyzed. INTERVENTIONS: Flexible bronchoscopy was performed for the diagnosis of tracheal stenosis and the evaluation of the treatment's effectiveness, and rigid bronchoscopy was applied for the dilatation of tracheal stenosis. MEASUREMENTS AND MAIN RESULTS: In the follow-up period, tracheal stenosis was observed in 7 of 208 patients (2 women, 5 men; 3.3%). The patients were divided into 2 groups as patients with tracheal stenosis (n = 7) and patients without tracheal stenosis (n = 201). There were no statistically significant differences between the 2 groups in terms of age, sex, body mass index, and comorbidities (p > 0.05). The mean duration of IMV of the patients with tracheal stenosis was longer than patients without tracheal stenosis (27.9 ± 13 v 11.2 ± 9 days, p < 0.0001, respectively). Three (43%) of the stenoses were web-like and 4 (57%) of them were complex-type stenosis. The mean length of the stenoses was 1.81 ± 0.82 cm. Three of the patients were treated successfully with bronchoscopic dilatation, and 4 of them were treated with tracheal resection. CONCLUSIONS: Tracheal stenosis developed in 7 of 208 (3.3%) patients with COVID-19 who were treated with IMV. The most important characteristic of patients with tracheal stenosis was prolonged IMV support.