Tracheobronchial resection and reconstruction: to wrap or not to wrap the anastomosis?

Introduction

In tracheobronchial segmental resection and reconstruction surgery, complications such as anastomotic separation and rupture can lead to life-threatening postoperative issues, including acute trachea-innominate artery fistula, pulmonary artery-tracheal fistula, bronchopleural fistula, mediastinitis, and tracheoesophageal fistula (1,2). Accurate preoperative planning of airway reconstruction strategies and ensuring proper tension and good healing of the anastomotic site are crucial for the prognosis of surgical patients (3). However, in certain situations such as malignant tracheal tumors, long-segment tracheal lesions, and complicated tracheal stenosis requiring laryngotracheal reconstruction, longer resection or irregular reconstruction may be necessary (4). In these cases, besides ensuring complete removal of the airway lesions, ensuring safe and optimal healing of the anastomosis is a focal point in airway surgery. The wrapping of autologous tissue materials around the anastomosis is considered a potential method to prevent complications at the anastomotic site (5). However, some argue that in airway reconstruction surgery, accurate suturing techniques and protecting surrounding airway structures (such as blood vessels and lymph nodes) are key to preventing anastomotic complications, making additional wrapping unnecessary (6). Moreover, once complications occur at the airway reconstruction anastomosis site, secondary surgery is usually required, and the adhesions formed between the anastomosis site and the wrapped material make secondary surgery for anastomotic complications extremely complicated.

Therefore, there are two opinions on the choice of wrapping the anastomosis after airway reconstruction: (I) protective wrapping of the anastomosis with surrounding tissues can improve surgical outcomes; (II) not wrapping the anastomosis has no effect on surgical outcomes. This article aims to explore the relationship between wrapping the anastomosis after airway reconstruction and short-term surgical outcomes, and to investigate whether wrapping the anastomosis can reduce the incidence of postoperative adverse events. Given the lack of large-scale research on this issue, we analyze the above cases into subgroups based on surgical difficulty to seek a more objective confirmation of the significance of this intraoperative procedure under different conditions. We present this article in accordance with the STROBE reporting checklist (available at https://tlcr.amegroups.com/article/view/10.21037/tlcr-24-868/rc).

Methods

This study was a retrospective single-center observational analysis of consecutive patients who underwent tracheobronchial resection and reconstruction for airway disease between January 2019 and December 2021. Airway lesions included cases of benign or malignant airway tumors, and exogenous airway injuries (including trauma and iatrogenic injuries). Cases with intraoperative interruption of surgery, age less than 12 years, or incomplete clinical data were excluded. The study was conducted in accordance with the Declaration of Helsinki (as revised in 2013). This study was reviewed and approved by the Research Ethics Committee of the First Affiliated Hospital of Guangzhou Medical University (No. ES-2023-062-03), and individual consent for this retrospective analysis was signed and collected from the patients. Their medical data and images would be demonstrated with their official permission.

Overall, 95 patients were included, and their age and comorbidities were quantified using the age-adjusted Charlson comorbidity index (ACCI) to normalize the baseline characteristics of the subjects, aiming to reduce disparities to the greatest extent feasible. All patients received a standard preoperative assessment. Based on computed tomography (CT) scans, bronchoscopy, and other exam results, surgical plans were identified preoperatively by an experienced airway surgery team. The surgical procedures were determined based on the patients’ general characteristics and lesion location, and were performed by this team using the anastomotic techniques recommended by the Massachusetts General Hospital tracheal surgery team. Minimally invasive surgery was considered in suitable patients, including video-assisted thoracoscopic surgery (VATS) and robotic-assisted thoracic surgery (RATS). The choice of wrapping material was based on factors such as lesion location and length, material size and blood supply, and ease of procurement. Surveillance bronchoscopy was performed on all patients with suspected anastomotic complications. Short-term anastomotic complications refer to complications observed within 30 days postoperatively via bronchoscopy. These included mild necrosis (defined as the anastomosis being covered by white or yellow purulent tissue), mild stenosis (defined as an anastomotic narrowing of less than 75% of the normal lumen), rupture (defined as partial or complete disruption of the tracheal wall at the anastomosis), and fistula (defined as an abnormal passage between the anastomosis and adjacent cavities or organs, such as the esophagus or pleural cavity). Long-term anastomotic complications referred to those observed beyond 30 days postoperatively via bronchoscopy. These included mild stenosis (defined as an anastomotic narrowing of less than 75% of the normal lumen without causing significant clinical symptoms), tracheomalacia (characterized by dynamic collapse and narrowing of the tracheal lumen during exhalation, as assessed by bronchoscopy), and fistula (defined as an abnormal passage between the anastomosis and adjacent cavities or organs, such as the esophagus or pleural space, leading to persistent respiratory symptoms and infections).

Cases that involved surgery with a resection length greater than or equal to 4.0 cm or at least one neoadjuvant treatment method (including chemotherapy, radiotherapy, immunotherapy, or combination treatment) were defined as complex airway reconstruction cases. Based on whether the wrapped anastomosis technique was performed during the surgery, the complex cases (42 cases) were divided into two subgroups: the wrapped subgroup (A1, 32 cases, 76.2%) and the non-wrapped subgroup (B1, 10 cases, 23.8%). The remaining cases (53 cases) were defined as standard low-tension airway reconstruction cases and divided into two subgroups: the wrapped subgroup (A2, 32 cases, 60.4%) and the non-wrapped subgroup (B2, 21 cases, 39.6%) (Figure 1). Further comparative analysis was conducted to assess the differences in surgical-related indicators between the subgroups with and without the wrapped technique. Clinical data, including demographic characteristics and perioperative outcomes, were collected.

Figure 1 Flow diagram for grouping.

Statistical analysis

Continuous data were summarized using descriptive statistics. Specifically, when data were normally distributed, they were represented by the mean and standard deviation (SD). Conversely, for data that did not follow a normal distribution, the median and interquartile range (IQR) were used to describe the central tendency and dispersion. To compare continuous variables between two groups, parametric and non-parametric tests were employed based on the distribution of the data. If the data were normally distributed and met the assumptions of homogeneity of variance, two-sample t-tests were used to assess the differences between the two groups. However, for data that were not normally distributed or violated the assumptions of parametric tests, the non-parametric Mann-Whitney U test was applied to determine group differences. For categorical variables, data were presented as counts and percentages. The associations or differences between categorical variables were analyzed using Chi-squared tests when the expected frequencies in each cell met the assumptions of the test. In cases where the expected frequencies were too low, Fisher’s exact test was used instead to provide a more accurate assessment of the associations between categorical variables. Throughout the study, a two-sided significance level of α=0.05 was adopted to determine statistical significance.

Results

Overall, 95 patients (31.6% female) were included with a median age of 50 years (IQR: 35–59 years). Based on the performance of airway anastomosis wrapping during complex tracheobronchial reconstruction, the cases were categorized into two subgroups (Table 1): the wrapped subgroup and the non-wrapped subgroup. Regarding general preoperative characteristics, no statistically significant differences were observed between the two subgroups in terms of gender, body mass index (BMI), comorbidities, ACCI, causes of airway disease, or neoadjuvant therapy (Table 1). Postoperative complications included pneumonia, atelectasis, atrial fibrillation, coagulation dysfunction, and lower limb venous thrombosis, among others. Among the 32 patients in subgroup A1, 10 cases experienced postoperative complications (31.2%), while in subgroup B1, 6 cases encountered postoperative complications (60.0%). No statistically significant differences were found between the two subgroups in terms of postoperative complications (P=0.14), long-term complications (P=0.88), or follow-up duration (P=0.39).

Regarding the short-term postoperative condition at the anastomotic site, in subgroup A1, 26 cases (81.2%) exhibited no abnormalities, while 6 cases (18.8%) presented with mild necrosis or stenosis, and no instances of anastomotic rupture or fistula. In subgroup B1, 4 cases (40.0%) had no abnormalities, 2 cases (20.0%) experienced mild necrosis or stenosis, and 4 cases (40.0%) encountered anastomotic rupture or fistula. The difference between the two subgroups was statistically significant (P=0.004) (Figure 2). And in subgroup B1, 3 cases experienced 30-day mortality, with the cause of death attributed to anastomotic fistula.

Figure 2 Comparison of postoperative short-term anastomotic complication and long-term anastomotic complication between the wrapped and non-wrapped subgroups in complex surgery group and standard surgery group.

The only discernible difference between subgroups that received standard surgery was the duration of the operation, with no significant statistical differences observed in surgical characteristics, postoperative outcomes, or follow-up data (Figure 2).

Discussion

As an eminent tracheal surgeon, Hermes C. Grillo described cases of wrapping the tracheal anastomosis with pleural flaps, suggesting it as a potential method to protect the anastomosis and avoid complications (7). This procedure was advocated by thoracic surgeons such as Ris et al. (8) and Rendina et al. (9), who believed that wrapping the anastomosis could help maintain airway continuity, fill the surrounding area to separate important organ structures, and provide additional protection to prevent anastomotic rupture, thereby reducing the risk of complications. Various autologous tissues, including pedicled muscle flaps, pleura, glands, and omentum, have also been reported for use in wrapping the anastomosis after airway reconstruction (10-12). However, some experts argue that preserving the surrounding tissues of the airway and ensuring accurate sutures are sufficient to prevent anastomotic complications, rendering additional wrapping unnecessary (6). Thus, the question of whether to wrap the anastomosis in tracheobronchial resection and reconstruction remains controversial.

Previous literature has suggested that the strategy for tracheobronchial reconstruction surgery mainly depends on the length of the patient’s tracheal lesion and the tension at the anastomotic site (13). Wright et al. and Tapias et al. demonstrated that tracheal segmental resections exceeding 4.0 cm are strongly associated with increased surgical failure rates (1,14). For mainstem bronchial segmental resection and reconstruction, there is currently no definitive data establishing a correlation between the length of resection and the tension of anastomosis. However, in clinical practice, surgeons typically adhere to a resection limit of 3.0 cm. The release maneuvers (such as pericardial and hilar release) performed during surgery can enhance bronchial mobility by approximately 1.0 cm. Therefore, in our study, high-tension anastomosis was defined in association with resection lengths of 4.0 cm or greater.

From the results, we found that the role of wrapping was more significant in complex tracheal surgery, both in terms of “short-term anastomotic complications” and “30-day mortality”. The statistically significant difference in short-term anastomotic conditions between the two subgroups in the complex surgery group (P=0.004) confirms the effectiveness of this procedure in this cohort. Regarding 30-day mortality, among the four cases with severe complications at the anastomotic site in the non-wrapped subgroup, three cases died within 30 days after surgery due to postoperative airway reconstruction anastomotic fistula. All these 3 cases were attributed to malignant tracheal tumors in the cervical or carinal segments. One case required reoperation within 30 days after surgery due to a tracheoesophageal fistula, with the reason for reoperation being an anastomotic fistula, which considerably extended the postoperative hospital stay. By comparing the results of standard tracheal surgery cases, we believe that implementing the tracheal anastomotic wrapping procedure is beneficial for patients undergoing long-segment tracheal resection (high-tension anastomosis, length of resection ≥4.0 cm) or those receiving neoadjuvant therapy.

With the updating of medical treatment options, the effectiveness of neoadjuvant therapy cannot be ignored. Although the efficacy of neoadjuvant therapy for long-segment or advanced tracheal malignant tumors has not been validated by prospective clinical trials, our clinical experience has preliminarily confirmed its effectiveness (15). Neoadjuvant therapy can lead to adhesions and fibrosis in the tracheal lesion region, potentially causing intraoperative bleeding and damage to surrounding tissues. This occurrence often increases the complexity and risk associated with surgical interventions. Additionally, compromised tissue vitality resulting from neoadjuvant therapy can hinder the healing of the anastomosis, particularly in cases requiring long-segment tracheal resection. Reports indicate that chemotherapy can induce both transient and relatively permanent immunodeficiency in patients, thereby elevating the risk of postoperative infections and affecting patient prognosis (16). Therefore, we have included the factor of “neoadjuvant therapy” within the scope of complex tracheal reconstruction. In actual surgical procedures, compared with cases without neoadjuvant therapy, the tracheal lesion segments of patients who had received neoadjuvant therapy were more rigid and closely adherent to surrounding tissues. For example, the membranous posterior wall of the trachea and the outer layer of the esophageal wall were often so tightly adherent that the space between them was almost indistinguishable to the naked eye. This made dissection difficult and prone to bleeding, while also increasing the risk of esophageal injury. During the anastomosis phase, incomplete separation of the trachea from peritracheal tissues further restricted tracheal mobility, thereby increasing the tension at the anastomotic site. In our study, 12 patients who underwent neoadjuvant therapy were included in the “complex surgery group”. Among them, 9 patients received a wrapping procedure intraoperatively and achieved favorable treatment outcomes postoperatively. However, 3 patients did not receive wrapping during surgery, and one of them (33%) developed postoperative anastomotic complications and eventually died. Although the small sample size precludes further statistical analysis, this result is meaningful and underscores the need to further investigate the significance of the wrapping procedure in tracheal surgeries following neoadjuvant therapy, especially in specific types such as neoadjuvant immunotherapy or radiotherapy.

For more complex scenarios, the wrapping procedure should ideally cover any concerning areas and reinforce the reconstruction with mattress sutures directly on the anastomosis. The materials should be wrapped circumferentially around the anastomosis. However, surgeons are concerned that this procedure may calcify and constrict the airway, leading to postoperative airway stenosis and resulting in long-term anastomotic complications, thereby affecting the patient’s long-term quality of life. When we separately compared the wrapping subgroup of the complex surgery group with the standard surgery group, we found no significant difference between them in terms of postoperative hospital stays and long-term anastomotic complications, which preliminarily explains the benefits and safety of the wrapping procedure.

No statistically significant difference was found in the standard surgery group. This raises an important question: is anastomotic wrapping an unnecessary procedure in standard airway surgery? Our study has shown that low-tension anastomotic wrapping does not significantly reduce the risk of short-term postoperative anastomotic complications (P=0.82) or long-term anastomotic complications (P=0.43). Anastomotic wrapping is indeed a technically demanding procedure, involving the harvesting, tailoring, moving, and suturing of the wrapping material, all of which prolongs the surgical time. Therefore, surgeons can avoid performing a wrapping procedure that increases the complexity and difficulty of an already technically demanding operation, thereby shortening the operation time.

Our preliminary findings suggest that wrapping the anastomotic site in complex airway reconstruction surgery positively impacts short-term surgical prognosis compared to not wrapping the anastomotic site. There was no significant statistical difference between the two subgroups in long-term complication occurrence until the last follow-up. However, due to the rarity of tracheobronchial diseases and the limitations of this retrospective study conducted in a single institution, there are shortcomings such as a small number of cases and a short follow-up period, and a lack of independent data analysis for each wrapping material. Further validation of its effectiveness is needed through randomized trials conducted in multiple centers. Objective data validation through laboratory techniques, such as anastomotic tension measurement and studies on angiogenic factors, is also necessary to clarify the impact of wrapping operations and other factors on the healing of airway reconstruction anastomosis, providing better surgical interventions for patients with such diseases.

Conclusions

The wrapping procedure has a relatively positive effect on the short-term prognosis of patients undergoing complex tracheobronchial resection and reconstruction, particularly in minimizing the risk of anastomotic complications to a certain extent. However, as our study has shown, it appears unnecessary for standard airway resection and reconstruction surgeries.

Acknowledgments

The abstract has been presented as a poster at the 2024 ESTS Annual Meeting.

Footnote

Reporting Checklist: The authors have completed the STROBE reporting checklist. Available at https://tlcr.amegroups.com/article/view/10.21037/tlcr-24-868/rc

Data Sharing Statement: Available at https://tlcr.amegroups.com/article/view/10.21037/tlcr-24-868/dss

Peer Review File: Available at https://tlcr.amegroups.com/article/view/10.21037/tlcr-24-868/prf

Funding: None.

Conflicts of Interest: All authors have completed the ICMJE uniform disclosure form (available at https://tlcr.amegroups.com/article/view/10.21037/tlcr-24-868/coif). S.L. serves as an unpaid editorial board member of Translational Lung Cancer Research from February 2025 to January 2026. The authors have no conflicts of interest to declare.

Ethical Statement: The authors are accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved. The study was conducted in accordance with the Declaration of Helsinki (as revised in 2013). The study was approved by the Research Ethics Committee of the First Affiliated Hospital of Guangzhou Medical University (No. ES-2023-062-03), and individual consent for this retrospective analysis was signed and collected from the patients. Their medical data and images would be demonstrated with their official permission.

Open Access Statement: This is an Open Access article distributed in accordance with the Creative Commons Attribution-NonCommercial-NoDerivs 4.0 International License (CC BY-NC-ND 4.0), which permits the non-commercial replication and distribution of the article with the strict proviso that no changes or edits are made and the original work is properly cited (including links to both the formal publication through the relevant DOI and the license). See: https://creativecommons.org/licenses/by-nc-nd/4.0/.

References

1. Wright CD, Grillo HC, Wain JC, et al. Anastomotic complications after tracheal resection: prognostic factors and management. J Thorac Cardiovasc Surg 2004;128:731-9. [Crossref] [PubMed]
2. Sihag S, Wright CD. Prevention and Management of Complications Following Tracheal Resection. Thorac Surg Clin 2015;25:499-508. [Crossref] [PubMed]
3. Auchincloss HG, Wright CD. Complications after tracheal resection and reconstruction: prevention and treatment. J Thorac Dis 2016;8:S160-7. [PubMed]
4. Madariaga MLL, Soni ML, Mathisen DJ, et al. Evaluation of Release Maneuvers After Airway Reconstruction. Ann Thorac Surg 2022;113:406-12. [Crossref] [PubMed]
5. Anderson TM, Miller JI Jr. Use of pleura, azygos vein, pericardium, and muscle flaps in tracheobronchial surgery. Ann Thorac Surg 1995;60:729-33. [Crossref] [PubMed]
6. Campisi A, Ciarrocchi AP, Congiu S, et al. Sleeve Lobectomy: To Wrap or Not to Wrap the Bronchial Anastomosis? Ann Thorac Surg 2022;113:250-5. [Crossref] [PubMed]
7. Grillo HC. Development of tracheal surgery: a historical review. Part 1: Techniques of tracheal surgery. Ann Thorac Surg 2003;75:610-9. [Crossref] [PubMed]
8. Ris HB, Krueger T, Cheng C, et al. Tracheo-carinal reconstructions using extrathoracic muscle flaps. Eur J Cardiothorac Surg 2008;33:276-83. [Crossref] [PubMed]
9. Rendina EA, Venuta F, de Giacomo T, et al. Parenchymal sparing operations for bronchogenic carcinoma. Surg Clin North Am 2002;82:589-609. vii. [Crossref] [PubMed]
10. Wang C, Dong J, Zhuang X, et al. Intraoperative methods for wrapping anastomoses after airway reconstruction: a case series. Transl Lung Cancer Res 2022;11:1145-53. [Crossref] [PubMed]
11. Chen J, Ang KL, Wang C, et al. Minimally Invasive Carinal Reconstruction Using Bronchial Flap and Omental Flap Reinforcement. Ann Thorac Surg 2022;113:e255-7. [Crossref] [PubMed]
12. Deng D, Xu F, Liu J, et al. Clinical application of pedicled thoracoacromial artery perforator flaps for tracheal reconstruction. BMC Surg 2020;20:299. [Crossref] [PubMed]
13. Mathisen D. Distal Tracheal Resection and Reconstruction: State of the Art and Lessons Learned. Thorac Surg Clin 2018;28:199-210. [Crossref] [PubMed]
14. Tapias LF, Ott HC, Mathisen DJ. Complications Following Carinal Resections and Sleeve Resections. Thorac Surg Clin 2015;25:435-47. [Crossref] [PubMed]
15. Li S, Ai Q, Liang H, et al. Nonintubated Robotic-assisted Thoracic Surgery for Tracheal/Airway Resection and Reconstruction: Technique Description and Preliminary Results. Ann Surg 2022;275:e534-6. [Crossref] [PubMed]
16. Romero Román A, Campo-Cañaveral de la Cruz JL, Macía I, et al. Outcomes of surgical resection after neoadjuvant chemoimmunotherapy in locally advanced stage IIIA non-small-cell lung cancer. Eur J Cardiothorac Surg 2021;60:81-8. [Crossref] [PubMed]