Scientific Letter
Delayed Right Main Bronchus Stenosis With Involvement of the Tracheal Carina After Blunt Chest Trauma: Successful Treatment With Tracheobronchial Anastomosis
Satoshi Hamadaa,b,
, Akihiro Ohsumic, Tatsuya Gotoc, Masatsugu Hamajic, Hiroshi Datec, Toyohiro Hiraid
Corresponding author
a Department of Advanced Medicine for Respiratory Failure, Graduate School of Medicine, Kyoto University, Kyoto, Japan
b Department of Respiratory Medicine, Ayabe City Hospital, Kyoto, Japan
c Department of Thoracic Surgery, Graduate School of Medicine, Kyoto University, Kyoto, Japan
d Department of Respiratory Medicine, Graduate School of Medicine, Kyoto University, Kyoto, Japan
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The anomalous bronchial artery originates two bronchial arteries, right and left. The five arrows point to 1: the origin at the aorta; 2: the first branch, which is a normal right intercostobronchial branch; 3: the second branch, which is an aberrant bronchial trunk; 4 and 5: the two vessels originate from the bronchial trunk to form right and left bronchial arteries.</p> <p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">B – Computerized tomography reconstruction arteriography view showing the tortuosity of the anomalous bronchial artery described in a (<elsevierMultimedia ident="202108020524369151"></elsevierMultimedia>).</p> <p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">C – Dynamic image showing the anomalous bronchial artery tortuous path around the left main bronchus.</p> <p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">D – Endovascular embolization of the abnormal vessel, occluded with 12 microcoils.</p>" ] ] ] "autores" => array:1 [ 0 => array:2 [ "autoresLista" => "Filipa Marujo, Filipe Veloso Gomes, Fernando Rodrigues, Pedro Flores" "autores" => array:4 [ 0 => array:2 [ "nombre" => "Filipa" "apellidos" => "Marujo" ] 1 => array:2 [ "nombre" => "Filipe Veloso" "apellidos" => "Gomes" ] 2 => array:2 [ "nombre" => "Fernando" "apellidos" => "Rodrigues" ] 3 => array:2 [ "nombre" => "Pedro" "apellidos" => "Flores" ] ] ] ] ] "idiomaDefecto" => "en" "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S1579212921002408?idApp=UINPBA00003Z" "url" => "/15792129/0000005700000008/v1_202108020523/S1579212921002408/v1_202108020523/en/main.assets" ] "en" => array:17 [ "idiomaDefecto" => true "cabecera" => "<span class="elsevierStyleTextfn">Scientific Letter</span>" "titulo" => "Delayed Right Main Bronchus Stenosis With Involvement of the Tracheal Carina After Blunt Chest Trauma: Successful Treatment With Tracheobronchial Anastomosis" "tieneTextoCompleto" => true "saludo" => "Dear Editor," "paginas" => array:1 [ 0 => array:2 [ "paginaInicial" => "551" "paginaFinal" => "552" ] ] "autores" => array:1 [ 0 => array:4 [ "autoresLista" => "Satoshi Hamada, Akihiro Ohsumi, Tatsuya Goto, Masatsugu Hamaji, Hiroshi Date, Toyohiro Hirai" "autores" => array:6 [ 0 => array:4 [ "nombre" => "Satoshi" "apellidos" => "Hamada" "email" => array:1 [ 0 => "sh1124@kuhp.kyoto-u.ac.jp" ] "referencia" => array:3 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] 1 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">b</span>" "identificador" => "aff0010" ] 2 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">*</span>" "identificador" => "cor0005" ] ] ] 1 => array:3 [ "nombre" => "Akihiro" "apellidos" => "Ohsumi" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">c</span>" "identificador" => "aff0015" ] ] ] 2 => array:3 [ "nombre" => "Tatsuya" "apellidos" => "Goto" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">c</span>" "identificador" => "aff0015" ] ] ] 3 => array:3 [ "nombre" => "Masatsugu" "apellidos" => "Hamaji" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">c</span>" "identificador" => "aff0015" ] ] ] 4 => array:3 [ "nombre" => "Hiroshi" "apellidos" => "Date" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">c</span>" "identificador" => "aff0015" ] ] ] 5 => array:3 [ "nombre" => "Toyohiro" "apellidos" => "Hirai" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">d</span>" "identificador" => "aff0020" ] ] ] ] "afiliaciones" => array:4 [ 0 => array:3 [ "entidad" => "Department of Advanced Medicine for Respiratory Failure, Graduate School of Medicine, Kyoto University, Kyoto, Japan" "etiqueta" => "a" "identificador" => "aff0005" ] 1 => array:3 [ "entidad" => "Department of Respiratory Medicine, Ayabe City Hospital, Kyoto, Japan" "etiqueta" => "b" "identificador" => "aff0010" ] 2 => array:3 [ "entidad" => "Department of Thoracic Surgery, Graduate School of Medicine, Kyoto University, Kyoto, Japan" "etiqueta" => "c" "identificador" => "aff0015" ] 3 => array:3 [ "entidad" => "Department of Respiratory Medicine, Graduate School of Medicine, Kyoto University, Kyoto, Japan" "etiqueta" => "d" "identificador" => "aff0020" ] ] "correspondencia" => array:1 [ 0 => array:3 [ "identificador" => "cor0005" "etiqueta" => "⁎" "correspondencia" => "Corresponding author." ] ] ] ] "resumenGrafico" => array:2 [ "original" => 1 "multimedia" => array:5 [ "identificador" => "fig0010" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => false "mostrarDisplay" => true "figura" => array:1 [ 0 => array:4 [ "imagen" => "fx1.jpeg" "Alto" => 894 "Ancho" => 1333 "Tamanyo" => 201963 ] ] ] ] "textoCompleto" => "<span class="elsevierStyleSections"><p id="par0005" class="elsevierStylePara elsevierViewall">Blunt chest trauma is a rare cause of acquired benign airway stenosis. Only 0.4–1.5% of these events induce airway injury, which mostly occurs in the right main bronchus and within 2<span class="elsevierStyleHsp" style=""></span>cm of the tracheal carina.<a class="elsevierStyleCrossRef" href="#bib0065"><span class="elsevierStyleSup">1</span></a> Half of all airway injuries are not identified during the first 24–48<span class="elsevierStyleHsp" style=""></span>h, because normal ventilation may be present despite the airway injury and because of non-specific symptoms and other injuries, such as head trauma, abdominal injuries, and multiple extremity fractures.<a class="elsevierStyleCrossRef" href="#bib0065"><span class="elsevierStyleSup">1</span></a> If airway injuries are not recognized early, an aberrant airway healing process can lead to the formation of granulation tissue and collagen deposition and, ultimately, to delayed tracheobronchial stenosis.<a class="elsevierStyleCrossRef" href="#bib0070"><span class="elsevierStyleSup">2</span></a> Although delayed tracheobronchial stenosis after blunt chest trauma is treated with bronchoscopic intervention (e.g., balloon dilation, laser ablation, and airway stents), surgical intervention, or a combination of these methods, no treatment consensus or guidelines have been established for this condition.<a class="elsevierStyleCrossRefs" href="#bib0070"><span class="elsevierStyleSup">2,3</span></a> The management of delayed tracheobronchial stenosis caused by blunt chest trauma highly depends on patient status, severity of symptoms, location and extent of stenosis, degree of distal pulmonary parenchymal destruction, and local expertise.<a class="elsevierStyleCrossRef" href="#bib0070"><span class="elsevierStyleSup">2</span></a> Here, we describe the case of a patient with delayed right main bronchus stenosis involving the tracheal carina after blunt chest trauma who was successfully treated with tracheobronchial anastomosis.</p><p id="par0010" class="elsevierStylePara elsevierViewall">A 34-year old male current smoker had been involved in a motor vehicle accident at the age of 21. He suffered bilateral pneumothorax, which was treated only with chest drainage tubes. The patient developed pneumonia every 12 years starting at the age of 24. During the pneumonia episodes, he complained of wheezing and dyspnea. The patient did not have any lower respiratory tract infections during childhood. Recently, he started having recurrent obstructive pneumonia every 12 months, which led him to visit the Department of Respiratory Medicine of the local hospital. Chest computed tomography (CT) showed ground grass opacity and consolidation in the right middle and lower lobes, and bronchial mucous retention with stenosis of the right main bronchus, the length of which was less than 1<span class="elsevierStyleHsp" style=""></span>cm (<a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>A, B). Flexible fiber-optic bronchoscopy (FOB) showed a fibrotic lesion causing almost complete stenosis of the proximal right main bronchus, with the exception of a pinhole located at the lateral posterior aspect of the stenosis (<a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>D). His forced vital capacity (FVC), forced expiratory volume in 1<span class="elsevierStyleHsp" style=""></span>s (FEV<span class="elsevierStyleInf">1</span>), FEV<span class="elsevierStyleInf">1</span>/FVC ratio, expiratory reserve volume (ERV), and residual volume (RV)/total lung capacity (TLC) ratio, were 92.4% (4.23<span class="elsevierStyleHsp" style=""></span>L), 61.4% (2.47<span class="elsevierStyleHsp" style=""></span>L), 58.39%, 76.8% (1.29<span class="elsevierStyleHsp" style=""></span>L), and 32.13%, respectively (<a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>F).</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><p id="par0015" class="elsevierStylePara elsevierViewall">The patient was referred to our hospital for treatment of the right main bronchus stenosis. We selected surgical intervention (supplemental video). Under general single-lung ventilation with a double-lumen tube, we performed a right posterolateral thoracotomy and found that the lung had adhered to the chest wall and that the middle and lower lobes showed consolidation. We opened the right main bronchus at the proximal side; however, the stenosis remained, and we resected half of the tracheal carina and the lower part of the trachea. At the distal side, the main bronchus was removed to the smallest extent possible, which was approximately 2<span class="elsevierStyleHsp" style=""></span>cm. Anastomosis was performed with continuous suture for the mediastinal side and interrupted suture for the other part using 4-0 polydioxanone suture, and pedicled pericardial fat tissue was used as a cover. The patient was discharged on postoperative day 12 without any postoperative complications. Pathological analysis of the resected specimen showed the presence of granulation tissue with a focal fibrosis lesion and no evidence of malignancy.</p><p id="par0020" class="elsevierStylePara elsevierViewall">Follow-up chest CT (<a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>C) and flexible FOB (<a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>E) performed 3 months postoperatively showed successful healing of the anastomosis with luminal patency. A follow-up pulmonary function test revealed improvement of the obstructive ventilatory defect based on FVC, FEV<span class="elsevierStyleInf">1</span>, FEV<span class="elsevierStyleInf">1</span>/FVC ratio, ERV, and RV/TLC ratio values of 101.3% (4.66<span class="elsevierStyleHsp" style=""></span>L), 93.3% (3.77<span class="elsevierStyleHsp" style=""></span>L), 80.9%, 98.8% (1.67<span class="elsevierStyleHsp" style=""></span>L), and 27.6%, respectively (<a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>G). The patient did not develop pneumonia for 10 months after the operation.</p><p id="par0025" class="elsevierStylePara elsevierViewall">If stenosis involves the tracheal carina, surgical intervention may be associated with an increased risk because of technical difficulties and a high level of postoperative complications, such as anastomotic dehiscence and restenosis.<a class="elsevierStyleCrossRefs" href="#bib0080"><span class="elsevierStyleSup">4,5</span></a> Two previous studies showed that delayed airway stenosis with involvement of the tracheal carina after blunt chest trauma was successfully treated with repeated balloon dilation and stent placement.<a class="elsevierStyleCrossRefs" href="#bib0090"><span class="elsevierStyleSup">6,7</span></a> Thus, it was considered that we should perform a bronchoscopic intervention; however, we decided on surgical intervention for the following reasons. First, we considered that we could perform tension-free anastomosis, because the stenotic lesion affected the main bronchus exclusively. Second, the stenosis did not induce the formation of a right lung abscess. Third, bronchoscopic treatments might require repeated interventions because of migration and formation of granulation and because of the recurrence of stenosis after stent removal.<a class="elsevierStyleCrossRef" href="#bib0100"><span class="elsevierStyleSup">8</span></a> Forth, the patient was young and his preoperative condition was good. In the present case, surgical intervention was an acceptable method for managing stenosis involving the carina. Previous studies reported no perioperative mortality by surgical intervention for benign airway stenosis.<a class="elsevierStyleCrossRefs" href="#bib0105"><span class="elsevierStyleSup">9,10</span></a> Therefore, surgical intervention should be considered in the future under the same condition.</p><p id="par0030" class="elsevierStylePara elsevierViewall">The median time from initial injury to diagnosis of delayed tracheobronchial stenosis is 6 months.<a class="elsevierStyleCrossRef" href="#bib0070"><span class="elsevierStyleSup">2</span></a> Kiser et al. reported an absence of association between time to the diagnosis of delayed tracheobronchial stenosis and the rate of successful surgical repair.<a class="elsevierStyleCrossRef" href="#bib0115"><span class="elsevierStyleSup">11</span></a> Perioperative complications related to surgical intervention for tracheobronchial stenosis includes empyema, rebleeding, stenosis, and fistula.<a class="elsevierStyleCrossRefs" href="#bib0070"><span class="elsevierStyleSup">2,12</span></a> The current patient was diagnosed 13 years after the initial motor vehicle accident and experienced no perioperative complications. The long-term complications or long-term follow-up outcomes are unknown<a class="elsevierStyleCrossRef" href="#bib0120"><span class="elsevierStyleSup">12</span></a>; therefore, we should carefully investigate the future disease profiles of this case.</p><p id="par0035" class="elsevierStylePara elsevierViewall">Here, we successfully treated a case of delayed airway stenosis involving the tracheal carina with surgical intervention. As the treatment consensus or guidelines for delayed airway stenosis after blunt chest trauma have not been established, a very careful clinical and radiological evaluation is needed to prevent peri- and post-operative complications before deciding on whether to adapt this technique.</p><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0010">Financial conflicts</span><p id="par0040" class="elsevierStylePara elsevierViewall">This study was funded in part by the JSPS KAKENHI 19K17634 (SH). The Department of Advanced Medicine for Respiratory Failure is a Department of Collaborative Research Laboratory funded by Teijin Pharma.</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0015">Conflict of interest</span><p id="par0045" class="elsevierStylePara elsevierViewall">Satoshi Hamada reports grants from Teijin Pharma, outside the submitted work.</p></span></span>" "textoCompletoSecciones" => array:1 [ "secciones" => array:4 [ 0 => array:3 [ "identificador" => "xres1555989" "titulo" => "Graphical abstract" "secciones" => array:1 [ 0 => array:1 [ "identificador" => "abst0005" ] ] ] 1 => array:2 [ "identificador" => "sec0005" "titulo" => "Financial conflicts" ] 2 => array:2 [ "identificador" => "sec0010" "titulo" => "Conflict of interest" ] 3 => array:1 [ "titulo" => "References" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "tieneResumen" => true "resumen" => array:1 [ "en" => array:2 [ "titulo" => "Graphical abstract" "resumen" => "<span id="abst0005" class="elsevierStyleSection elsevierViewall"><p id="spar0005" class="elsevierStyleSimplePara elsevierViewall"><elsevierMultimedia ident="fig0010"></elsevierMultimedia></p></span>" ] ] "apendice" => array:1 [ 0 => array:1 [ "seccion" => array:1 [ 0 => array:4 [ "apendice" => "<p id="par0055" class="elsevierStylePara elsevierViewall">The following are the supplementary data to this article:<elsevierMultimedia ident="upi0005"></elsevierMultimedia></p>" "etiqueta" => "Appendix A" "titulo" => "Supplementary data" "identificador" => "sec0020" ] ] ] ] "multimedia" => array:3 [ 0 => array:7 [ "identificador" => "fig0005" "etiqueta" => "Fig. 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 1165 "Ancho" => 2169 "Tamanyo" => 307263 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">Coronal chest CT image (A) and three-dimensional chest CT image (B) acquired before the operation and three-dimensional chest CT image acquired 3 months after the operation (C). Flexible fiber-optic bronchoscopic images before the operation (D) and 3 months after the operation (E). Flow-volume loops before the operation (F) and 3 months after the operation (G).</p>" ] ] 1 => array:6 [ "identificador" => "upi0005" "tipo" => "MULTIMEDIAECOMPONENTE" "mostrarFloat" => false "mostrarDisplay" => true "Ecomponente" => array:3 [ "fichero" => "mmc1.mp4" "ficheroTamanyo" => 12146766 "Video" => array:2 [ "flv" => array:5 [ "fichero" => "mmc1.flv" "poster" => "mmc1.jpg" "tiempo" => 0 "alto" => 0 "ancho" => 0 ] "mp4" => array:5 [ "fichero" => "mmc1.m4v" "poster" => "mmc1.jpg" "tiempo" => 0 "alto" => 0 "ancho" => 0 ] ] ] "descripcion" => array:1 [ "en" => "<p id="spar0010" class="elsevierStyleSimplePara elsevierViewall"><span class="elsevierStyleItalic">Supplemental video</span>: Posterolateral thoracotomy was performed via the fourth intercostal space. Intrapleural adhesions at the apex and the base were dissected. Then, the right main bronchus was dissected and encircled with a vessel tape. The bronchus intermedius was also dissected. Hilar release was performed with pericardiotomy around the inferior pulmonary vein. The proximal dividing line was determined on the basis of intraoperative bronchoscopy. The mediastinal side of the trachea and the mediastinal side of the right main bronchus were trimmed. Anastomosis was performed on the mediastinal side in a continuous manner and that on the other side in an interrupted manner. The sealing test was negative for air leak at the anastomosis site. The anastomosis was covered with a pericardial fat pad.</p>" ] ] 2 => array:5 [ "identificador" => "fig0010" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => false "mostrarDisplay" => true "figura" => array:1 [ 0 => array:4 [ "imagen" => "fx1.jpeg" "Alto" => 894 "Ancho" => 1333 "Tamanyo" => 201963 ] ] ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0015" "bibliografiaReferencia" => array:12 [ 0 => array:3 [ "identificador" => "bib0065" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Blunt tracheobronchial trauma" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:2 [ 0 => "E. Shemmeri" 1 => "E. 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| Year/Month | Html | Total | |
|---|---|---|---|
| 2024 November | 5 | 4 | 9 |
| 2024 October | 28 | 10 | 38 |
| 2024 September | 27 | 8 | 35 |
| 2024 August | 46 | 31 | 77 |
| 2024 July | 29 | 12 | 41 |
| 2024 June | 40 | 16 | 56 |
| 2024 May | 61 | 16 | 77 |
| 2024 April | 19 | 30 | 49 |
| 2024 March | 34 | 11 | 45 |
| 2024 February | 16 | 17 | 33 |
| 2024 January | 20 | 23 | 43 |
| 2023 December | 21 | 25 | 46 |
| 2023 November | 20 | 13 | 33 |
| 2023 October | 33 | 28 | 61 |
| 2023 September | 30 | 20 | 50 |
| 2023 August | 25 | 29 | 54 |
| 2023 July | 21 | 21 | 42 |
| 2023 June | 25 | 11 | 36 |
| 2023 May | 25 | 14 | 39 |
| 2023 April | 26 | 26 | 52 |
| 2023 March | 37 | 35 | 72 |
| 2023 February | 30 | 13 | 43 |
| 2023 January | 23 | 21 | 44 |
| 2022 December | 30 | 27 | 57 |
| 2022 November | 47 | 19 | 66 |
| 2022 October | 32 | 34 | 66 |
| 2022 September | 30 | 24 | 54 |
| 2022 August | 30 | 35 | 65 |
| 2022 July | 38 | 28 | 66 |
| 2022 June | 24 | 30 | 54 |
| 2022 May | 28 | 24 | 52 |
| 2022 April | 29 | 19 | 48 |
| 2022 March | 38 | 32 | 70 |
| 2022 February | 16 | 21 | 37 |
| 2022 January | 1 | 0 | 1 |
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