End-to-side anastomosis in complex tracheal resection and reconstruction: a case series study

Abstract

Background: The development of current anesthetic and surgical techniques has increased the success rate of complex tracheal resection and reconstruction. End-to-end anastomosis is the prevailing method, while the end-to-side approach has also been reported to be practical and suitable. The current study aimed to demonstrate the feasibility and advantages of the end-to-side anastomosis method in specific cases.

Methods: We summarized 6 cases of patients with tracheobronchial tumors who received different end-to-side airway reconstructions in our center. Their clinical features and surgical procedures were also described. Postoperative follow-up was conducted to monitor their complications and prognosis.

Results: Among the patients involved in the study, 2 patients with tumors involving the bronchus intermedius received auto-lung transplantations under general anesthesia, 3 patients with tumors involving the lower trachea and carina underwent reconstruction under non-intubated combined anesthesia, and 1 patient with left main bronchus (LMB) involvement received surgery under venoarterial extracorporeal membrane oxygenation (VA ECMO)-supported non-intubated anesthesia. The surgical procedures were completed successfully without surgical or anesthetic incidents. Patients 1 and 2 underwent auto-lung transplantation with distal stumps and trachea end-to-side anastomosis (right lower lobe and right basal segment). Patients 3 and 4 received right main bronchus (RMB) to lateral trachea reconstruction, while Patients 5 and 6 underwent LMB to tracheal wall anastomosis. Anastomotic buttressing was performed using the thymus and mediastinal tissue. The patients were discharged within 2 weeks of the operation. No severe postoperative complications were reported, with the exception of Patient 5, who required a prolonged intensive care unit (ICU) stay with antibiotics due to pneumonia. Anastomotic necrosis, dehiscence, or stenosis were not observed in the postoperative bronchoscopy.

Conclusions: End-to-side anastomosis is a feasible and effective surgical method in airway reconstructions. This method facilitates tension-free anastomosis, which is crucial for surgical prognosis and decreasing complications. The reported cases had ideal surgical results during follow-up. The long-term outcomes of the end-to-side method require further evaluation.

Keywords: Trachea; anastomosis; case series; end-to-side; reconstruction.

Figure 1

The preoperative CT scan images of the cases. (A) Patient 1 showed a 4 cm × 5 cm irregular mass in the RMB with hilar and mediastinal lymph node enlargement (yellow arrow); (B) patient 2 showed an 8 cm × 10 cm broccoli-like tumor in the bronchus intermedius involving the distal RMB (yellow arrow); (C) patient 3 showed a 3.0 cm irregular mass on the carina involving the orifice of the RMB with mediastinal lymph node enlargement; (D) patient 4 showed a 3.0 cm irregular mass with a rough and vascularized surface located in the carina. The proximal margin of the tumor was 1.2 cm above the carina, and the distal margins were 1 cm and 0.8 cm from the orifices of the LMB and RMB (yellow arrow); (E) patient 5 showed a longitudinal 3.5 cm irregular neoplasm involving the right and partial anterior wall of the thoracic trachea 2.5 cm from the carina (yellow arrow); (F) patient 6 showed an oval mass in the lower trachea measuring 4 cm longitudinally and involving the carina and the LMB orifice (yellow arrow). CT, computed tomography; RMB, right main bronchus; LMB, left main bronchus.

Figure 2

The three-dimensional model and diagram of Patient 3. (A) The tracheobronchial tree three-dimensional model of Patient 3 demonstrating an irregular mass located in the lower trachea involving the carina and partial RMB; (B) the postoperative three-dimensional model of Patient 3 after end-to-side airway reconstruction; (C) the diagram of the reconstruction of Patient 3 (trachea-LMB end-to-end anastomosis and trachea-RMB end-to-side anastomosis). RMB, right main bronchus; LMB, left main bronchus.

Figure 3

The postoperative CT scan of Patients 1 and 2. (A) Patient 1 received an end-to-side anastomosis via right basal segment stump and lateral tracheal wall. The graft is well inflated without anastomotic stenosis or airway occlusion; (B) Patient 2 received an end-to-side anastomosis via right lower lobe bronchial stump and lateral tracheal wall. The graft is well inflated without anastomotic stenosis or airway occlusion.