Tracheal resection

Tracheal resection is an operation on the windpipe – the tube which connects the voicebox to the lungs. It involves a short section of the windpipe being removed and the cut ends of the windpipe are stitched back together.

A tracheal resection is performed when there is a significant narrowing in the windpipe. The length of the narrowing is short otherwise a bigger operation called a slide tracheoplasty will need to be carried out. The narrowing may either be something your child is born with, or something they develop after birth, most often due to injury to the windpipe.

Narrowing of the windpipe can cause severe breathing difficulties, which can be life threatening if your child has a chest infection. Narrowing of the windpipe can also make chest infections more likely to occur.

Breathing difficulties can cause feeding problems which can lead to insufficient intake of nutrients and weight loss. It is therefore important that these problems are identified early and treated if necessary.

The windpipe normally has C-shaped rings of cartilage within the wall to make it more rigid. Occasionally some of these rings may develop in a circular shape, like a ring, which means they will not grow at the same rate as the rest of the windpipe and sometimes there may be rings missing. Injury to the windpipe, which can be due to a breathing tube used during a stay on intensive care, can result in a ring of scar tissue developing in the wall of the windpipe.

Your child is likely to require investigation with bronchoscopy (a camera down the windpipe) and bronchography (X-rays of the windpipe taken at the same time) before having tracheal resection. These investigations are performed while your child is under general anaesthetic, and so they are completely asleep. This will diagnose the problem and help plan surgery.

After the decision has been made to perform tracheal resection, your child will be admitted on the morning of surgery. The operating surgeon and anaesthetist will see you and you child, explain the procedure in more detail and you will be asked to sign a consent form.

Your child will be taken to the anaesthetic room, where you may accompany them, and will be anaesthetised with general anaesthetic. Following this, the operation will be performed.

An incision is made in the middle of the chest and the breast bone is split to allow the windpipe to be located. The chest is opened which exposes the heart and the large blood vessels entering and leaving the heart with windpipe is located behind these.

Once the windpipe has been located and the narrow section is identified, a bypass machine will be connected, which takes over the function of the heart and lungs. The surgery can then be performed to cut the windpipe, removing the narrow section of windpipe. The cut ends of the windpipe are then stitched back together.

Often, a bronchoscopy is undertaken at this point to look inside the windpipe and ensure the repair has been successful. Once ready, the bypass machine is disconnected and the heart and lungs resume their normal function.

The chest is closed with stitches and drain tubes are inserted to drain away any blood and allow antiseptic fluid to flow around the site of surgery, reducing the risk of infection.

The child is then transferred to the Cardiac Intensive Care Unit (CICU) with a breathing tube going into the windpipe connected to a ventilator machine that controls your child’s breathing.

There are risks associated with any surgical procedure and these will be explained to you in detail by the operating surgeon. These complications infrequently occur with tracheal resection but nevertheless require explanation.

• Infection and bleeding can occur following any operation and these risks are reduced with the use of antibiotics and careful surgical technique. 
• The use of the bypass machine in the operating theatre has risks including damage to organs such as the brain, kidneys, heart and lungs. This may result from clots of blood entering the circulation or bleeding due to blood thinning treatment to prevent clots. These risks occur rarely and the cardiac surgical team as Great Ormond Street Hospital (GOSH) are highly experienced and skilled at using the bypass machine with low complication rates. 
• Where the join is made between the cut ends of the windpipe, a leak of secretions and air may occur. This is very rare and the repair is tested to ensure this does not occur. However, if it does happen it may involve going back to the operating theatre to correct the problem.
• After the procedure there is a very small risk that a type of life support known as ECMO (extra-corporeal membrane oxygenation) may be needed for a period of time on the intensive care unit. ECMO is similar to the bypass machine used in the operating theatre and is used if the lungs or heart are not functioning well after the procedure is completed. 
• There will be a scar where the skin incision is made on the front of the chest. Often this heals very well and is barely noticeable within a few years. On rare occasions scars can become thickened and red (called hypertrophic or keloid scarring) but it is difficult to predict which patients will develop this type of scar. 
• Where the cut ends of the windpipe are joined together, scarring can lead to narrowing of the windpipe which may require balloon dilatation procedures at regular intervals for some time after the operation. It is difficult to predict which patients will develop this problem.

On the evening after the procedure there will be many tubes and wires connected to your child, which can be alarming to see. However, these are necessary in order to keep your child well hydrated, comfortable, pain free and to let the staff know at the earliest opportunity if there are any problems. Medications such as antibiotics to reduce infection and anti-reflux medicines are started.

The tubes and wires decrease in number over the next few days, as the healing process takes place and your child’s condition becomes less critical.

After tracheal resection, the breathing tube is often removed one or two days after surgery. Sometimes it may take longer to remove the tube, depending on how your child is after the operation. It is often necessary to repeat a bronchosocpy and bronchography before and after the breathing tube has been removed to ensure there is no floppiness or narrowing of the airway. Once the tube has been removed, your child will be transferred from CICU to a ward.

A speech and language assessment will be carried out to ensure that your child’s swallowing function is normal and that it is safe to start feeding by mouth. Once this happens, and any other outstanding issues are addressed, your child will be discharged home. Antibiotics are continued three times a week to prevent against chest infections.

A follow-up bronchoscopy and bronchography will normally be undertaken a few months after the procedure, providing there are no problems. This may have to be carried out earlier if needed.

Based on the results of this investigation, further follow-up will be decided. Sometimes it is necessary to stretch the inside of the windpipe with a balloon if there is any residual narrowing, and occasionally this may have to be repeated several times (this is referred to as balloon dilatation). You will be given contact details of the Clinical Nurse Specialists on the Tracheal team to contact if you require any further advice or if you think there are any problems. Follow-up may also be undertaken by cardiology and respiratory teams, depending on other medical issues.

If you live a long distance away from Great Ormond Street Hospital, we will liaise with a team in your local centre, who may be able to take over the follow-up from this procedure at some point.

The aim of tracheal resection is to allow the child to develop an appropriately sized airway that grows with them so they can lead a normal life.

Antibiotics can be required over the winter period each year to reduce the risk of chest infections for the first few years.

There may however be ongoing problems with the windpipe which may require repeated bronchoscopy and bronchography procedures with balloon dilatation of the windpipe during the first few years after the operation.

There may also be problems with chest infections and chest symptoms that require input from the respiratory team and chest physiotherapy. However, the vast majority of children who undergo this procedure do very well indeed and need very little ongoing care in the long-term.